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Quitline Operations A Practical Guide to Promising Approaches


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									                       Quitline Operations:
A Practical Guide to Promising Approaches
                                  Quitline Operations:
           A Practical Guide to Promising Approaches

                                      Ordering Information

           For additional information on this guide or to request a copy, contact:

                                                  Tamatha Thomas-Haase, MPA
                                            North American Quitline Consortium

 North American Quitline Consortium. Quitline Operations: A Practical Guide to
Promising Approaches. Phoenix, AZ: North American Quitline Consortium; 2005.

                      Quitline Operations: A Practical Guide to Promising Approaches
Quitline Operations: A Practical Guide to Promising Approaches
                                                   Quitline Operations:
                            A Practical Guide to Promising Approaches

                                                                             Table of Contents


Acknowledgements .........................................................................................iii

Chapter 1 .............................................................................................................1
The Delivery of Pharmacotherapy in Conjunction with Quitline Services

Chapter 2............................................................................................................11
Working with the Medical Community: Healthcare and Fax Referral Programs

Chapter 3 ...........................................................................................................21
The Minimal Data Set: Moving Toward Implementation

Chapter 4 ...........................................................................................................27
Promoting Quitline Services: Managing Messages in the Face of Shifting Budgets

Chapter 5 ...........................................................................................................37
Making the Most of Quitline Resources through Public-Private Partnerships

Chapter Six ........................................................................................................45
Reaching Priority Populations with Quitline Services

Appendices ........................................................................................................53
        A     Free NRT Programs – A Report on the Reach, Efficacy,
              and Cost Effectiveness of NRT give-away Programs
              Conducted in New York State ...............................................................A1
        B     QuitWorks Hospital Guide ....................................................................B1
        C     Wisconsin’s Fax to Quit FAQs for providers ........................................C1
        D     Wisconsin’s Fax to Quit FAQs for patients...........................................D1
        E     Wisconsin’s Fax to Quit Referral Form.................................................E1

                                              Quitline Operations: A Practical Guide to Promising Approaches
Quitline Operations: A Practical Guide to Promising Approaches
                                                         Quitline Operations:
                                  A Practical Guide to Promising Approaches


   The North American Quitline Consortium (NAQC) is a community of professionals dedicated to
improving the effectiveness of and access to tobacco dependence treatment through quitlines. Together,
quitline funders, service providers, researchers and non-governmental organizations from the United
States and Canada work to maximize the role that quitlines play in helping tobacco users quit. NAQC
members not only serve as leaders to promote this vital public health service, but also as mentors and
resources to one another in our efforts to promote best practices in quitline operations, promotion,
and interventions.
    In October 2004, NAQC began a six-month conference call series dedicated to quitline operations.
This series of calls, Quitline Operations: Current, Promising and Best Practices, created a shared
learning environment in which promising practices and real world experiences were shared, steps to
implementation highlighted, barriers and challenges discussed and movement toward best practices
encouraged. In the absence of an evidence base for most quitline operations, our work centers on asking
the important, sometimes difficult, questions with the hope of creating future progress.
   This resource guide is in many ways a compilation of information and discussion shared during the
conference call series. However, it also contains additional tools, highlights promising approaches, and
asks additional questions. While background resource materials and call summaries were written for
each call topic, NAQC believed that compiling this information in one place to promote practical
application of the contents was critical.

How the Guide is Organized
Each chapter is dedicated to a specific operations-related topic.
       q   The Delivery of Pharmacotherapy in Conjunction with Quitline Services
       q   Working with the Medical Community: Healthcare and Fax Referral Programs
       q   The Minimal Data Set: Moving Toward Implementation
       q   Promoting Quitline Services: Managing Messages in the Face of Shifting Budgets
       q   Making the Most of Quitline Resources through Public-Private Partnerships
       q   Reaching Priority Populations with Quitline Services

                                               Quitline Operations: A Practical Guide to Promising Approaches   i

         Each chapter contains a summary of the current landscape and highlights several practical
     examples. Throughout the document icons are intended to assist in identifying additional information,
     potential barriers to implementation, and tips that highlight successful practices. Mentor resources are
     identified to foster creation of a colleague community.
     About the Icons

                  The                       The Bigger Picture icon identifies important background
                  Bigger Picture            information that helps to frame the discussion.

                Examples                    The Examples from Practice icon illustrates a topic by
             from Practice                  highlighting a state or provincial project or program.

              Here's a                      The Here’s a Tip icon is used to highlight a good practice to
                Tip                         follow or something that has proven useful to others.

                                            The Caution icon indicates an area where careful attention is
                Caution                     needed. This icon will be especially useful for identifying
                                            potential barriers or roadblocks to success.

               Research                     The Research in Action icon highlights examples of research
                  in Action                 that are moving us closer to best practices and informing our
                                            progress. This icon is also used to identify research questions
                                            that still need to be answered.

                 Mentor                     The Mentor Resources icon indicates people who are willing to
                Resources                   share their expertise, answer your questions or help you to solve
                                            a problem.

         This guide is intended for use by anyone who is responsible for some aspect of making quitline
     services available to tobacco users – primarily those who fund quitlines, those who deliver the
     service, those who promote quitlines and those who conduct research to bring us closer to best
     practices. Every quitline operates in a different social, political and economic environment, and offers
     a different range of services to a different range of audiences. Because of the great diversity and
     complexity of quitlines, it is impossible for every Example from Practice highlighted in this guide to
     “speak” to everyone. However, our hope is that you will think about how these examples and our
     advice fit your state/province, your target audience, your environment…your quitline.
         This guide is meant to do just that – guide. It is not intended to be rigid, but to inform your
     practice and to help you get started. Think about what adaptations need to be made and make use of
     our wise mentor resources when you get stuck. Our goal is to establish best practices for the topics
     addressed in this guide and we are happy to have you join us in this effort.

ii   Quitline Operations: A Practical Guide to Promising Approaches
                                                        Quitline Operations:
                                 A Practical Guide to Promising Approaches


Quitline Operations: A Practical Guide to Promising Approaches was prepared by The North American
Quitline Consortium (NAQC) under the general editorship of Tamatha Thomas-Haase, MPA and the
co-chairs of the NAQC Tools and Resources Working Group:
   Christopher Anderson, BA                              Abby Rosenthal, MPH
   Program Director                                      Cessation Strategic Coordinator
   California Smokers’ Helpline                          Centers for Disease Control and Prevention
   Department of Family and Preventive Medicine          National Center for Chronic Disease Prevention
   University of California, San Diego                   and Health Promotion
                                                         Office on Smoking and Health
   Diana Dampier
   Network Manager
   Canadian Network of Smokers’ Helplines

We also wish to thank the following contributors who so generously shared their expertise:
   Rob Adsit                                             K. Michael Cummings, PhD, MPH
   Education and Outreach Programs Supervisor            Chairman
   University of Wisconsin Center for Tobacco            Department of Health Behavior
   Research and Intervention                             Roswell Park Cancer Institute
   Brenda Bryan                                          Kathy Danberry
   Consultant                                            Cessation Program Manager
   North American Quitline Consortium                    Division of Tobacco Prevention
                                                         West Virginia Department of Health
   Sharon Campbell, PhD
   Director                                              Karen Fainman
   Evaluation Studies                                    Marketing Manager
   University of Waterloo                                Canadian Network of Smokers’ Helplines
   Paula Celestino                                       Nikki George
   New York Smokers’ Quitline Coordinator                Smokers’ Helpline Coordinator
   Department of Health Behavior                         The Lung Association of Newfoundland and
   Roswell Park Cancer Institute                         Labrador
   Jeanne Chiquoine                                      Rachel Grossman
   Delaware Tobacco Cessation Manager                    Manager
   South Atlantic Division                               Market Development
   American Cancer Society                               Free & Clear, Inc.

                                             Quitline Operations: A Practical Guide to Promising Approaches   iii

        Todd Hill, LiCSW, LADC                                    Rebecca “Bec” Ruiz McGill
        Tobacco Specialist                                        Cessation Unit Director
        Cessation Programs                                        Arizona Smokers’ Helpline
        Vermont Department of Health                              University of Arizona
        Jana Johnson, MD, MPH                                     Scott E. Sherman, MD, MPH
        Medical Director                                          Smoking Cessation Coordinator
        Tobacco Prevention and Control Branch                     Veterans Administration
        Division of Public Health                                 Greater Los Angeles Healthcare System
        North Carolina Department of Health and                   Professor of Medicine
        Human Services                                            University of California, Los Angeles
        Randi Lachter, MPH                                        Charlene Smith
        Intervention Program Manager                              Project Coordinator
        Minnesota Partnership for Action Against                  Wyoming Health Resources Network
                                                                  Sue Swartz, MD, MPH
        Gail Luciano                                              Medical Director
        Manager                                                   Center for Tobacco Independence
        Smokers’ Helpline Ontario
                                                                  Juliet Thompson
        Canadian Cancer Society
                                                                  Tobacco Cessation Coordinator
        Judith Mills, MPH                                         Tobacco Prevention and Control Program
        Outreach Coordinator                                      Washington Department of Health
        California Smokers’ Helpline
                                                                  Brooke Thorington
        University of California, San Diego
                                                                  Public Information Coordinator
        Joanne Pike, MA, LPC                                      Quitline Coordinator
        Quitline Director                                         Tobacco Prevention and Control Division
        American Cancer Society                                   Alabama Department of Public Health
        Connie Revell, MA                                         Debra Voss
        Deputy Director                                           Account Executive
        Smoking Cessation Leadership Center                       Michigan Quitline
        University of California, San Francisco                   Leade Health, Inc.
        Dave Robertson-Palmer                                     Donna Warner, MA, MBA
        Program Officer                                           Director of Cessation Initiatives
        Office of Programs and Mass Media                         Tobacco Control Program
        Tobacco Control Programme                                 Massachusetts Department of Health
        Health Canada
                                                                  Ann Wendling, MD, MPH
        Stephen Rothemich, MD, MS                                 Director of Intervention Programs
        Associate Professor of Family Medicine                    Minnesota Partnership for Action Against Tobacco
        Virginia Commonwealth University

        The production of this guide would not have been possible without the funding and support of
     NAQC’s sponsors: the American Legacy Foundation, the National Cancer Institute, and the Centers for
     Disease Control and Prevention. We thank them for their generosity.
       In these pages you will also find the invaluable leadership, guidance and wisdom of the North
     American Quitline Consortium’s Executive Director, Linda Bailey, JD, MHS.

iv   Quitline Operations: A Practical Guide to Promising Approaches
                                                                        Chapter                   1
                                The Delivery of Pharmacotherapy
                             in Conjunction with Quitline Services

According to information gathered from the first NAQC conference call on quitline operations
(October 2004), there are nine states that provide no-cost Nicotine Replacement Therapy (NRT) and
five states that provide low-cost NRT to eligible quitline callers. Eligibility requirements differ among
the states and typically include one or more of the following. Caller must:
                    q   Be 18 years of age or older.
                    q   Be uninsured or underinsured.
                    q   Be Medicaid-insured.
                    q   Be willing to quit within a specific time frame.
                    q   Be willing to participate in proactive telephone counseling.
                    q   Use an identified number of cigarettes per day.

The chart below provides an overview of state quitline approaches to offering NRT.

      q Low-cost NRT and Zyban® to all Arizona residents over 18 years of age through a
        voucher system.

     q Low-cost NRT to Medicaid-eligible callers who are willing to quit within 30 days.

     q Offers certification of enrollment for MediCal NRT benefits.

                                                Quitline Operations: A Practical Guide to Promising Approaches   1
Chapter 1

              q No-cost NRT to qualifying low-income callers.

               q Low-cost NRT to eligible callers.

               q   Quitline Iowa is currently involved in several county-based pharmacotherapy
                   distribution programs. A coalition individually requests funds and works with the
                   state to develop a program that suits the community’s needs. All NRT distribution
                   programs require the individual caller to participate in a cessation program such as
                   Quitline Iowa. Most allow callers to receive additional coupons based on continued
                   participation in a cessation program. County coalitions work with local pharmacies,
                   so an individual can only redeem their NRT coupon at a specific location.
                   The current coupon distribution programs include:
                        – $10 coupon good towards the purchase of NRT and Zyban®.
                        – Coupon for a free, two-week supply of nicotine patches.
                        – Coupon that offsets the cost of pharmacotherapy. For each product there is a
                           specific price that the individual must pay. The discount usually amounts to
                           at least a 50% reduction. One coupon can be used to purchase more than one
                           type of product.
                        – $25 coupon good toward the purchase of NRT.

              q No-cost NRT to callers who are ready to quit within 30-days, have no insurance or lack an
                NRT benefit, and agree to proactive telephone counseling.

              q No-cost NRT (patches or gum) is available to uninsured residents. Participants receive
                an initial one-month supply and must comply with the proactive phone counseling
                schedule in order to receive the second (final) month of NRT.

              q No-cost NRT to uninsured or underinsured (lack an NRT benefit) adult (18+) callers who
                are willing to quit within 30-days and agree to participate in proactive telephone counseling.

              q Mississippi has a separate quitline geared toward college students. This quitline offers NRT
                to eligible callers.

2    Quitline Operations: A Practical Guide to Promising Approaches
                                                                                                    Chapter 1

New York
  q New York has periodically offered no-cost NRT to all adult smokers who smoke 10+
    cigarettes per day and have no contraindications. Beginning in the Fall of 2004, the
    NYS Smokers’ Quitline began to provide access to a free two-week starter kit of NRT
    as part of its routine service, along with one proactive call to those who receive the kit.
    In addition, uninsured and Medicaid clients who call the quitline are eligible for up to a
    six-week supply of NRT, plus four proactive telephone counseling calls.

  q No-cost NRT (patches and gum) to uninsured and Medicare callers.

South Dakota
  q Low-cost nicotine patches (up to 8 weeks) or Zyban® (up to 3 months) to tobacco users
    who agree to participate in proactive telephone counseling. Participants must be 18
    years or older.
   q   In January 2002, the South Dakota Department of Health began offering free NRT
       (patch and gum) or bupropion to selected groups of smokers who enrolled in telephone
       counseling through the South Dakota Quitline. These groups included: individuals that
       self-identified as having a chronic disease; Native Americans; persons who lived in
       predefined zip codes who had a demonstrated high smoking prevalence; and persons
       18 to 25 years of age. In June 2002, the offer was expanded to include free medication
       for all smokers who participated in counseling through the quitline. Once enrollment
       was verified and a prescription received for bupropion, participants were mailed
       medications through a South Dakota pharmacy.
       The program is now running in a limited format and requires a co-payment. South
       Dakota is currently working on a Morbidity and Mortality Weekly Report article
       highlighting the results of this program.

  q No-cost NRT to any quitline caller willing to make a quit attempt within 30 days.
    Medicaid reimburses the state for all Medicaid-insured callers who receive
    counseling and/or pharmacotherapy.

  q No-cost NRT to uninsured and Medicaid-insured callers who are willing to quit
    within 30-days and agree to participate in proactive telephone counseling.

West Virginia
  q No-cost NRT to uninsured and Medicaid-insured callers who agree to proactive
    telephone counseling. West Virginia also offers low-cost NRT to public employees
    insured through the Public Employees Insurance Agency.

                                          Quitline Operations: A Practical Guide to Promising Approaches   3
Chapter 1

         In Canada, none of the 10 provincial quitlines offer pharmacotherapy, nor are vouchers available for
     pharmacotherapy. Canadian quitline counselors discuss pharmacotherapy with callers as an option for
     assistance with quitting and answer related questions related to medications. In addition to providing
     information on how to use medication effectively, callers are encouraged to contact their pharmacist or
     physician for further guidance. If reduced-cost pharmacotherapy is available in their province, callers
     are informed as to how it can be accessed.

            Prince Edward Island (PEI)
               q In PEI, the health department provides $75 per year of NRT to clients who participate
                 in group counseling.

              q In Quebec, the provincial government reimburses 85% of the cost of nicotine patches
                and Zyban® if obtained by physician prescription.

                Bigger Picture
         Quitlines typically place eligibility requirements on NRT distribution due to the high cost of
     offering pharmacotherapy, as well as wanting to ensure the delivery of an intervention with the highest
     likelihood of producing a quit (for example, requiring enrollment in proactive counseling sessions in
     combination with NRT use).
         Improved strategies are being implemented to provide NRT at reduced costs through quitlines.
     States have set distribution quotas, implemented voucher systems to alleviate direct-mail costs or refer
     quitline callers with insurance and prescription coverage back to their insurance provider for medication.
     While dealing with limited budgets, states are finding ways to eliminate barriers to pharmacotherapy.

        from Practice
         The Michigan quitline provides free NRT (patches or gum) for uninsured residents. Michigan sends
     a one-month supply of NRT to a caller who must comply with the proactive counseling schedule to
     receive the second month supply. Fulfillment of the first month of NRT occurs after a participant has
     provided identification to verify age and residency and a completed medication contraindications form.
     If contraindications exist, a physician approval/consent form is required. Thirty-four percent of initial
     NRT requests are not filled due to incomplete paperwork.
         The second NRT shipment is sent if the participant completes the quit date call with their coach,
     which occurs within 30 days of enrollment. Eighty-one percent of participants using NRT complete the
     quit date call and thus get the second month supply of NRT.

4    Quitline Operations: A Practical Guide to Promising Approaches
                                                                                                         Chapter 1

    There is an additional cost to handle and ship NRT in two installments. Michigan has not yet
completed a cost analysis to determine if these costs offset the costs of unused medication that may
result in shipping the two-month supply at enrollment and losing participants to follow-up. Michigan
finds that the quit date call rate among NRT users is greater than 80%, which is notable among an
uninsured or underinsured population.
    The Minnesota Partnership for Action Against Tobacco (MPAAT) also “splits” NRT fulfillment into
two shipments and began doing so after realizing, through evaluation, that clients may not be using the
entire week-week supply of NRT for various reasons. There was also a concern about the number of
counseling sessions enrollees were completing. Given the clinical and cost implications of these two
issues, MPAAT changed its approach to NRT distribution in the summer of 2003. Clients now must
remain in counseling to qualify to receive the second shipment of medication.

  from Practice
    NRT “give-away” programs are also being explored by quitlines. New York offers four examples
of free NRT give-away programs in which local tobacco coalitions utilized the New York State
Smokers’ Quitline to screen and register eligible smokers for the free medications.
       q   In one location, eligible smokers were sent a voucher for a two-week supply of either
           nicotine patches or gum, redeemable at a local pharmacy.
       q   In another location, smokers were eligible to receive free either a one or two-week
           supply of nicotine patches sent directly to their home.
       q   Finally, in New York City, smokers were eligible to receive a six-week supply of
           nicotine patches (two weeks each of 21 mg, 14 mg and 7 mg nicotine patches) sent to
           their home. Some participants in the New York City program also received a callback
           to provide telephone counseling support.
     In each case, eligibility was limited to adults (18 years and older) who were current daily smokers
of 10 or more cigarettes per day, who agreed to make a quit attempt in the next seven days, and who
reported no contraindications for using either the nicotine patch or gum. The overall goal of each
initiative was to increase access to NRT, considering a previously noted barrier of perceived high cost
by tobacco users.
   The different New York programs varied the amount, type and means of distributing NRT to
smokers, thus creating a natural experiment.
       q   Reach of the programs was evaluated by determining the proportion of eligible
           smokers enrolled.
       q   Efficacy of each program was evaluated by examining self reported use of the
           medications, quit attempts and quit rates in program participants and comparing
           these measures to the rates expected without offering free NRT to quitline callers.

                                               Quitline Operations: A Practical Guide to Promising Approaches   5
Chapter 1

                 A standardized telephone survey was developed to follow up with program participants
                 in order to assess their use of the nicotine medications sent to them and their smoking
                 status measured four to five months after enrollment in the program.
             q   Call volume was measured before, during and after the free NRT give-away in order to
                 determine whether these interventions could serve as an alternative method for driving
                 calls to the quitline.
             q   Cost effectiveness of each intervention approach was contrasted in terms of getting
                 smokers to call the quitline and the quit rate.
     (For specific evaluation results, see Appendix A for report entitled “Free NRT Programs: A Report on the Reach,
     Efficacy, and Cost-Effectiveness of NRT give-away Programs Conducted in New York State.”)

         If considering a free NRT give-away, please make note of lessons learned by New York:
             q   Call volume increased dramatically with little to no paid media promotion – 400,000
                 calls in three days! Be aware of how such an effort can overtax the quitline system.
                 New York hired 50 part-time registration specialists to handle the anticipated increase in
                 volume, and also shortened the intake process so they could take more calls per day.
                 Even so, the great majority of calls were not answered.
             q   It is important to buy the product in bulk. New York programs were able to do so by
                 partnering with drug companies and Eckerd pharmacy.
             q   The trade-off between reach and efficacy needs to be balanced when resources are
                 limited. Since the Fall of 2004, the New York Smokers’ Quitline has offered a free
                 two-week supply (starter kit) of NRT as part of its routine service. Those who receive
                 this kit are also provided one proactive counseling call from a cessation specialist.

        from Practice

         While some states that offer no-cost or low-cost NRT through their quitline choose to have the
     medication delivered to the caller via direct-mail, there are states that choose to use different methods
     for getting the product to the caller. The State of Maine contracts with the Center for Tobacco
     Independence (CTI) to operate and evaluate a comprehensive tobacco treatment initiative that includes
     a helpline, a medication program and a tobacco treatment training program. The Medication Program
     uses a paperless electronic “voucher” to distribute NRT to eligible callers.

6    Quitline Operations: A Practical Guide to Promising Approaches
                                                                                                           Chapter 1

    The Maine HelpLine specialists screen for contraindications and provide dosing recommendations,
and ask the caller to identify a local pharmacy where they prefer to pick up their product. An authorization
form is then submitted electronically to a pharmacy benefit management company (this company is
under contract with the state and the relationship between all three entities must be collaborative and
well established), who then contacts the pharmacy with medication specifics. The participant then goes
to the pharmacy to pick up their medication. Four weeks are provided with the first “voucher” and the
final four-week supply “voucher” requires contact with the Helpline.
   Some important numbers to keep in mind when
considering Maine’s approach:                                         Caution
       q    Half of callers to the Maine HelpLine
                                                                     Should we evaluate free NRT
            are uninsured or Medicaid-insured.
                                                                give-away programs as promotional
       q    About 80% of eligible callers are                   campaigns – either in lieu of or as an
            authorized for NRT.                                 adjunct to more traditional mass media
       q    97% of these callers pick up NRT                    or grassroots promotional campaigns? If
            from their pharmacy.                                you are considering free NRT give-away
       q    89% of NRT dispensed is for patch                   programs as an alternative to traditional
            and 11% for gum.                                    mass media promotion of your quitline,
                                                                it is important to consider whether or
       q    Six-month quit rate for callers receiving
                                                                not this approach is as effective at
            counseling is only 22%; for callers
                                                                driving unaided cessation in the
            counseled and using NRT it is 35%.
                                                                general tobacco using population, or at
       q    1/3 of all smokers report hearing about             supporting the state or provincial goal
            the Helpline from a health professional.            of changing the norms associated with
                                                                smoking and quitting.
    Here's a
   The following are questions to consider in offering no-cost or low-cost NRT through your quitline:
       q    What is the goal of offering NRT to quitline callers?
       q    What, if any, eligibility requirements will you require for a caller to access
            the NRT?
       q    How will the NRT be delivered to the caller?
              – Via direct mail from the quitline vendor?
              – Via a voucher system? Does this approach, while effective at controlling costs,
                create barriers for the tobacco user and an additional administrative burden?
       q    What costs other than the cost of the NRT will be associated with implementing this
            approach (for example: promotion of the new service, increased vendor costs associated
            with delivering the new distribution protocol and mailing the product; possible

                                                 Quitline Operations: A Practical Guide to Promising Approaches   7
Chapter 1

                  enhanced evaluation costs in order to determine differences in quit rates and service
                  satisfaction for those receiving NRT compared with those callers who do not)?
              q   What are the needs for medical oversight and training of quitline staff?
              q   How will you balance promotion of NRT, service demand and service capacity?

            from Practice

         Beginning October 1, 2004, the State of Oregon’s Tobacco Prevention and Education Program
     (TPEP) began offering all qualified Oregonians a two-week starter kit of nicotine patches when they
     call the Oregon Tobacco Quit Line. They anticipate achieving the following goals through their
     NRT Initiative:
             1) Increase the number of calls to the quitline without adding any supplemental paid
                advertising. In other states, simply announcing the offer of free NRT to the media has
                been enough to increase call volume dramatically. In Minnesota, for example, calls to
                the quitline leveled off at three times their normal volume with NRT provision and no
                additional advertising.
             2) Improve the quit rates for those who call the quitline. Many studies have shown that
                NRT helps people quit and can as much as double quit rates. (Fiore MC, Bailey WC,
                Cohen SJ, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline.
                Rockville, MD: U.S. Department of Health and Human Services. Public Health Service.
                June 2000).
             3) Encourage health plans and health systems to cover cessation resources for their
                members or to improve access to services already offered. The Oregon Tobacco Quit
                Line has always been a public-private partnership. By supplying Oregonians with two
                weeks of the usual eight-week course of NRT, they are hoping to give health systems an
                incentive to provide better cessation resources to members.
         TPEP will also be studying the effect of providing uninsured Oregonians with varying amounts of
     NRT. Based on studies recently completed, they have found that most uninsured quitline callers are
     using less than a full course of NRT. Oregon will randomize
     those callers agreeing to participate in the study into three cells:
     (1) Callers who receive two weeks of patches and two counseling
     phone calls; (2) Callers who will receive a full eight weeks of           Does providing free NRT
     patches and two counseling phone calls; and (3) Callers who will      to quitline callers create a
     receive three weeks of patches and four counseling phone calls.       disincentive for health plans
     Quit rates of all three groups will be measured to assess if an       to provide a cessation benefit
     “accelerated quit” (the two or three week course of NRT) achieves     for their members?
     a similar number of quits as the full eight-week course.

8    Quitline Operations: A Practical Guide to Promising Approaches
                                                                                                          Chapter 1

         in Action

                                 Effectiveness of a Veterans Administration Program
                                                       to Increase Quitline Referrals
                               Scott Sherman, MD, MPH; Preety Kalra, MS; Nancy Takahashi, MPH;
            James Canfield, BS-CCPT; Elizabeth Gifford, PhD; John Finney, PhD; Ware Kuschner, MD
                                          VA Greater Los Angeles and Palo Alto Healthcare Systems
    Three main approaches exist to help primary care patients quit smoking – primary care-based
treatment, smoking cessation program referral and referral to telephone counseling (quitline). The
effectiveness of a system to increase quitline referrals was tested in this study.
    Ten of 18 Veterans Administration (VA) sites in California were randomly allocated to receive
the Telephone Care Coordination Program, which included simple “two-click” referral, proactive care
coordination, medication management (transdermal nicotine patch and/or bupropion), and follow-up
(2, 4, 6, and 8 weeks; 6 months). The VA care coordinator initiated a three-way call to the California
Smokers’ Helpline, which subsequently provided a standard 30 to 45 minute counseling call. At
baseline and the end of the 10-month intervention, providers were asked how many patients they had
referred to telephone counseling within the last month.
    In 10 months, 2,965 referrals had been received, and 1,156 (39%) were unable to be reached
despite at least three attempts. Seventy-three patients (2%) were excluded and 391 (13%) were not
interested in quitting. The remaining 1,345 (45%) patients were connected to the Helpline. At six-month
follow-up, 335 patients (25%) were abstinent (30-day point prevalence). When investigators compared
the change in average number of reported telephone counseling referrals from baseline to the end of the
study, there was a large increase among intervention site providers (baseline – 1.5/month, follow-up –
15.7/month) and no change at control sites (baseline – 2.2/month, follow-up – 1.0/month) (p<0.01).
    The Telephone Care Coordination Program generated a large number of referrals from primary
care, nearly half of whom were connected with the Helpline. Providers at intervention sites reported
referring many more patients to telephone counseling than providers at control sites. Long-term
abstinence among patients referred was excellent (25% at six months).

    While the evidence base for the effectiveness of NRT in helping people quit is well established,
effective delivery of NRT to quitline callers is not yet clear. Like other aspects of quitline operations,
there is a lack of evidence that points to best practices. Evaluation of current programs, innovative
approaches to challenges highlighted through evaluation and ongoing research will surely lead to the
effective delivery of NRT to quitline callers.

                                                Quitline Operations: A Practical Guide to Promising Approaches   9
Chapter 1

            Questions on NRT distribution through quitlines services? The people below
            have much wisdom to share:

            Paula Celestino                                     Sue Swartz, MD, MPH
            Coordinator                                         Medical Director
            New York Smokers’ Quitline                          Center of Tobacco Independence
            Roswell Park Cancer Institute                          207.662.7152
               716.845.8817                                        swarts@mmc.org
                                                                Deb Voss
            K. Michael Cummings, PhD, MPH                       Account Executive
            Chairman                                            Michigan Quitline
            Department of Health Behavior                       Leade Health, Inc.
            Roswell Park Cancer Institute                          734.995.0699, ext. 203
                716.845.8456                                       dvoss@leadehealth.com
                                                                Ann Wendling, MD, MPH
            Randi Lachter, MPH                                  Director of Intervention Programs
            Intervention Program Manager                        Minnesota Partnership for Action on Tobacco
            Minnesota Partnership for Action Against                952.767.1411
            Tobacco (MPAAT)                                         awendling@mpaat.org

            Tim McAfee, MD, MPH
            Chief Medical Officer
            Free & Clear, Inc.

10   Quitline Operations: A Practical Guide to Promising Approaches
                                                                        Chapter                   2
                         Working with the Medical Community:
                        Healthcare and Fax Referral Programs

       Bigger Picture
    Quitlines throughout the US and Canada approach partnerships with the healthcare community in
differing ways. For some, these partnerships are meant to supplement promotional efforts of quitline
services and are limited to efforts focused on individual physicians or practices. The result of these
activities is increased referrals to the quitline and a general increase in awareness of services. These
efforts may also be coupled with training for physicians and their staff on the brief intervention and/or
practice-level systems strategies that are essential to effectively treat tobacco users.
    More complex partnership efforts targeted toward whole systems (health plans and healthcare
delivery systems, for example) may involve fax referral and feedback programs, collaboration to build
and promote a universal system of referral to quitline services, or assessment of quitline callers’ insurance
coverage in order to better link with covered cessation services offered through their health plan.

   from Practice
    The Massachusetts’ QuitWorks program – a fax referral system linking healthcare systems in
Massachusetts to the services and resources of the Massachusetts Try To STOP TOBACCO Resource
Center – has been operating since 2002, took over a year to develop and involved nearly 40 people from
partnership organizations. The program was launched with 1,400 provider practices in May 2002 and
has since expanded to 23 hospitals, a 14-site clinic system, 17 community health centers (in process),
the Women’s Health Network and the WIC program statewide. At the heart of this program is a
universally endorsed fax referral form with feedback reports to referring providers and participating
institutions. Other features of QuitWorks include hospital and health center detailing and training, and
access to the combined resources and expertise of seven health plans.

                                                Quitline Operations: A Practical Guide to Promising Approaches   11
Chapter 2

         When a fax referral form is received by the quitline from a provider, the patient is contacted and
     receives up to five proactive counseling calls, access to interactive web-based assistance, materials
     mailed to their home and referrals to local cessation programs. Providers who fax referral forms to the
     quitline receive two fax back reports – one within a week of the referral to report on initial patient
     contact and services selected, and one approximately seven months later that reports on patient
     outcomes. Custom aggregate reports are also prepared quarterly for health plans and for hospitals and
     health centers, as requested. Massachusetts has found that frequent communication and feedback on
     patient outcomes is critical to maintaining participation in the program.
         Currently, the QuitWorks program generates 60% of quitline call volume in Massachusetts. In fact,
     having this program in place was key to the survival of cessation treatment services in Massachusetts
     after a 90% budget reduction in 2003. Between 1994 and 2000, the quitline was dependent chiefly on
     mass media campaigns to generate call volume, also producing significant month-to-month fluctuations
     in volume. The concept of a quitline linked to the healthcare system evolved in 2000 in part as an
     alternative method to drive and stabilize call volume. It was also designed to fill a critical gap for
     providers who wanted to intervene with their patients, but lacked a consistent resource to refer patients
     for more intensive counseling support.
         Massachusetts does not presently have a mass media campaign related to the quitline and has not
     had a campaign since 2000. While the cost of serving QuitWorks clients is higher than for self-referred
     clients (due to the callbacks needed to reach the client and administering the fax reporting system), it is
     important to remember there are no promotion costs incurred by the Department or the quitline. Partner
     health plans promote the program to both their members and their provider networks.
         In terms of utilization, approximately 15 to 17 % of participating office practices have enrolled at
     least one patient in the program. Despite significant promotion by health plans, there is still difficulty in
     changing individual provider behavior. Some health plans are now offering financial incentives to
     providers in order to encourage provider interventions and enrollment in QuitWorks. To implement
     QuitWorks in hospitals and health centers, participation from upper-level management is essential to
     introduce or amend systems needed to identify smokers, intervene, offer QuitWorks, enroll patients
     and receive feedback reports. A hospital team must be assembled to attend an initial QuitWorks
     presentation, conducted on site by the QuitWorks team (e.g. the University of Massachusetts Medical
     School and the Department). The typical hospital team consists of a vice president for patient care or
     clinical integration, the quality improvement manager, clinical leadership (e.g. medical and unit
     directors) and the director of clinical education. Some hospitals invite all unit directors (inpatient and
     outpatient) to attend.
           Most hospitals introduce QuitWorks in selected pilot units and then expand the program
     hospital-wide. It takes several months or longer for most hospitals to introduce and roll out the
     program and to educate and train clinicians. Unfortunately, some hospitals have chosen to limit
     implementation of the QuitWorks program to certain departments within the hospital. QuitWorks
     tries to discourage this limited approach.

12   Quitline Operations: A Practical Guide to Promising Approaches
                                                                                                            Chapter 2

    Data is collected on every person who enrolls in the program and QuitWorks conducts 100%
follow-up evaluation with clients at six-months from first contact with the quitline. Recently, a pilot
outcome evaluation was conducted on 984 clients – 653 were referred to the quitline through
QuitWorks and 326 were self-referred.
        q   Overall, follow-up rates of 56% – these were higher for self-referred clients (62%) than
            they were for QuitWorks clients (53%).
        q   There was a difference noted in stages of change – 60% of QuitWorks clients were in
            preparation and 70% of self-referred clients were in preparation.
        q   30 % of QuitWorks clients and 19% of self-referred clients were in contemplation.
        q   7% in both groups were in the action stage.
        q   In terms of quit rates, 20.5% were quit at current 30-day and this number was
            slightly higher for women.
        q   Younger and very old smokers were more likely to successfully quit.
        q   There was a higher quit rate for higher education levels.
        q   Just over half of all quitline clients reported using NRT, with slightly higher use
            (54.8%) among QuitWorks clients than among those who self-referred (52.5%).
(See Appendix B for a copy of the QuitWorks Hospital Guide)

    Here's a
       Based on the Massachusetts experience, feedback reports seem to be a way to reinforce
    changes in provider behavior and the intervention system in healthcare institutions. If you are
    considering implementing a fax referral system, don’t forget to consider the importance of
    provider feedback.
        q   What data and patient outcomes are your healthcare partners interested in receiving and
            how often?
        q   Will you charge for the feedback reports, and if so, how much is needed to offset the
            costs of their development?
            Remember, setting aside promotion costs, the difference in cost between the QuitWorks
    client and the self-referred client is incurred with the data systems and feedback reporting.
    Last year, the Massachusetts quitline reported a cost of $27 per completed intake/assessment
    for a self-referred client, compared with $40 for a QuitWorks client intake/assessment and
    provider feedback report. The subsequent costs per client for both counseling and evaluation
    are identical.

                                                  Quitline Operations: A Practical Guide to Promising Approaches   13
Chapter 2

             from Practice

         Newfoundland and Labrador Smokers’ Helpline (SHL) launched the first fax referral program in
     Canada in partnership with the Newfoundland and Labrador Medical Association (NLMA). The
     Community Action and Referral Effort (CARE) program pilot took place in March 2004 with 40
     physicians and was then rolled out to all 930 physicians in the province in April 2004. At the launch
     event held at the conclusion of the pilot phase of the project, the physician who had referred the most
     patients to the helpline was thanked publicly.
            The program’s objectives are:
               q   To increase the number of community referrals by health professionals through a
                   proactive call service.
               q   To build upon and strengthen community partnerships in tobacco control.
               q   To increase access to effective and evidence-based smoking cessation programs.
         The CARE program targets all physicians in Newfoundland and Labrador, as well as all smokers
     (70% of whom see their family physician at least once a year). In the future, the program hopes to
     expand its target audience to all health professionals in the province including social workers, teachers,
     pharmacists, dentists, psychologists and guidance counselors. The second phase of the project is
     planned for the fall of 2005 in which 6,000 nurses will be targeted. New forms and a toolkit will be
     developed specifically for this group.
          Together, the NLMA and the Newfoundland and Labrador Lung Association (NLLA) developed a
     letter introducing the CARE program and encouraging physicians to use this referral service with their
     patients. This letter also instructs physicians on how to use the materials.
         Essentially, the CARE program asks physicians to discuss with their patients how the helpline can
     assist with quitting, request permission from a patient to make a referral to the helpline and get the
     patient’s signature on the referral form authorizing treatment. The form also includes the name of the
     referring physician and the client’s contact information. The fax referral form is received by the
     helpline and contact is initiated. Physicians receive a monthly fax that identifies the number of patients
     they have referred and whether or not the helpline has made contact. Physicians also receive a fax
     thanking them for their support and encouraging them to continue their efforts. Physicians NOT referring
     to the program receive a fax from the NLLA reminding them of the program, highlighting the number
     of referrals and the great efforts of their colleagues and encouraging them to come on board.
     Results / Measures of Success
               q   From March to August 2004, there have been a total of 523 new referrals to the SHL
                   as a direct result of the CARE program. This represents a 100% increase in smokers
                   receiving services from the quitline.
               q   There are currently over 120 physicians, or 13% of all physicians in the province,
                   actively involved in the program.

14   Quitline Operations: A Practical Guide to Promising Approaches
                                                                                                          Chapter 2

       q   The CARE program has doubled call volume during the summer, which is typically
           a slow time for the quitline. It is expected to triple call volume during the fall and
           winter months.
       q   64.5% of the clients during the six-month time frame heard about the SHL through the
           CARE program. The closest promotional campaign ever was television, which brought
           22% at one given time.
       q   A press conference was held at the six-month evaluation mark to announce these results
           and an award was presented to the top three referring physicians.
       q   At one year, 21% of all physicians are referring to the helpline. Thirty-six percent of
           general practitioners are referring.

   from Practice

    In the fall of 2004, Smokers’ Helpline (SHL) Ontario began working in collaboration with the
Clinical Tobacco Intervention Program (CTI) to deliver an exciting fax referral pilot project called Quit
Connection. CTI is a collaborative effort of the Ontario Medical Association (OMA), Ontario Dental
Association (ODA) and the Ontario Pharmacists’ Association (OPA). The pilot is designed to recruit
and mobilize physicians, pharmacists and dentists to engage their patients in the process of quitting
smoking and to maintain practitioners’ involvement over the long-term.
    Funding from Health Canada was received to develop and deliver the Quit Connection pilot project
in order to determine the feasibility of:
       q   Recruiting and supporting practitioners (physicians, dentists and pharmacists) to
           participate in the CTI and SHL Ontario fax referral program.
       q   Increasing utilization of SHL Ontario by tobacco users.
       q   Creating linkages between practitioners and SHL Ontario in the delivery of smoking
           cessation interventions.
    Practitioners interested in this program will be recruited by CTI through promotional activities
including direct mail, professional association publications and web-based promotion. Practitioners
participating in the program will identify patients interested in receiving telephone counseling
from SHL Ontario. Patients will be asked to complete and sign a form with their consent, contact
information and availability to receive a telephone call from SHL Ontario. Forms completed by patients
will be faxed to SHL Ontario by the practitioner’s workplace. SHL Ontario Quit Specialists will then
complete the referral by contacting the patients, based on patient availability, and offering cessation
    The Quit Connection pilot project has been funded through March 31, 2005. A formal evaluation of
the pilot will be conducted for making decisions about continuing, altering and possibly expanding the
program. We look forward to the results of this collaborative effort.

                                                Quitline Operations: A Practical Guide to Promising Approaches   15
Chapter 2

                We know that proactive enrollment in quitline services is a feasible means of recruiting
            quitline participants, and there is gathering anecdotal evidence that it can serve as a tool for
            encouraging systems change and changing provider behavior. It also has the potential to
            replace or augment mass media promotion of quitlines, an important consideration for under-
            funded tobacco control programs. What we don’t yet know is how effective quitline services
            are for proactively enrolled participants, since the studies demonstrating efficacy recruited
            their participants reactively. An argument can be made that tobacco users who call a quitline
            on their own may be more amenable to quitting than those whose healthcare providers have
            them fill out a fax referral form. More research in this area is needed.

                in Action

                                          Project Title: Quitlink – A Leveraging Solution to
                                                                               Tobacco Counseling
                                   Source of Funding:      U.S. Department of Health and Human Services,
                                                      Agency for Healthcare Research and Quality (AHRQ)
                                   Project Period:                               09/03/2004 - 08/31/2006
                                   Principal Investigator:                Stephen F. Rothemich, MD, MS,
                                       Virginia Commonwealth University, Department of Family Medicine

     Project Description:
         Despite a broader base of evidence for how to help smokers in primary care practices than for
     any other health behavior, there is a disconnect between the evidence for what works and the reality
     of actual practice. The Surgeon General’s guideline outlines a spectrum of activities, but few
     practices have been able to accomplish these tasks as described. The problem is not simply a matter
     of providers lacking knowledge, skills, attitude and reinforcement (though all of these are real issues
     to varying degrees for many providers).
         A bigger problem is the lack of office support systems to conduct cessation counseling amidst
     the competing demands of busy primary care visits, now averaging close to 12 minutes each.
     Even with identification systems to find smokers, going beyond simple advice to providing the
     recommended two to three minutes of assistance to more than a handful of the smokers seen on any
     given day is more than most providers can accomplish. In order to provide counseling to more
     smokers in primary care offices, creative strategies that make counseling smokers feasible without
     an unrealistic burden to practices is necessary. One answer may be to provide a true linkage between

16   Quitline Operations: A Practical Guide to Promising Approaches
                                                                                                             Chapter 2

practices and telephone counselors at the American Cancer Society (ACS) that takes advantage of the
strengths of each and creates a partnership for helping more patients stop smoking.
    The primary purpose of this project is to test whether the delivery of A3-5 (Assess, Assist and
Arrange) is enhanced by a system that couples an expanded vital sign intervention with fax referral of
preparation-stage patients for telephone counseling provided by the American Cancer Society (ACS)
and feedback to the provider. The question will be examined in a randomized trial, with practices as the
unit of analysis and with a control intervention consisting of a conventional vital sign intervention. The
experiment will therefore compare what intervention and control practices accomplish beyond simply
identifying patients who use tobacco.
    The secondary purpose of this study is to assess contextual factors that might affect implementation
of the intervention and account for its ultimate success or failure. In particular, to assess: (1) environmental
and practice-level factors that affect practices’ ability to successfully implement and use the intervention
and; (2) patient characteristics beyond readiness to change (i.e., age, gender, race/ethnicity) that affect
willingness to use the quitline and complete counseling. The study will be conducted at 16 diverse
family practices in Virginia.
    (The 5 A’s – ASK about tobacco use, ADVISE to quit, ASSESS willingness to make a quit
attempt. ASSIST in quit attempt, and ARRANGE for follow-up – are the five major steps to
intervention in the primary care setting as described in the Treating Tobacco Use and Dependence
Clinical Practice Guideline.)

    Here's a
    Consider how well your fax referral system will handle NRT.
        q   Some fax referral systems elect to have NRT remain the responsibility of the
            physician and actually write this into the protocol that the physician follows when
            delivering the fax referral intervention.
        q   Other fax referral systems depend on the quitline to screen for contraindications and
            dose NRT. Typically, the NRT is mailed directly to the caller by the quitline or their
            distribution service.

                                                  Quitline Operations: A Practical Guide to Promising Approaches   17
Chapter 2

        from Practice

         The New California Gold Rush program is a unique partnership, launched in the Spring of 2004,
     and is California’s means of implementing the American Dental Hygienist Association’s national
     tobacco cessation initiative. The partners include the California Dental Hygienists’ Association
     (CDHA), the California Smokers’ Helpline, Pfizer and the Smoking Cessation Leadership Center
     (SCLC) at the University of California, San Francisco. The partners are working to have every dental
     hygienist in California hand out at least one gold card – a marketing piece for the California Smokers’
     Helpline – by the Spring of 2005.
          CDHA, the Helpline and SCLC began the project as a version of the national dental hygienists’
     effort to promote cessation. Another partner, Pfizer, joined the project after a regional sales director
     learned about the Helpline’s gold card and recognized an opportunity for the Pfizer sales representatives
     to promote their own products while also promoting smoking cessation in general. (Pfizer sells the
     Nicotrol inhaler, which is among the products discussed with smokers who call the Helpline.) Pfizer
     initially purchased 20,000 gold cards and began having sales representatives distribute them in dental
     offices. Two months later they began handing them out in family practice offices as well.
         Evaluation of this project is important and a clever tracking system has been developed to track the
     number of orders for materials by dental hygienists. The Helpline tracks calls from dental offices and
     medical practices and makes monthly reports on how many calls are received. In addition, the CDHA
     district liaisons are tracking their districts’ efforts, as are Pfizer representatives who distribute gold
     cards in dental offices throughout California. The partners are also able to track how many hygienists
     log onto the Gold Rush page on the CDHA web site.

             Here's a
                Competition seems to not only encourage provider participation in fax and healthcare
            referral systems, but it also adds an element of fun. The New California Gold Rush program is
            offering two prizes to do just that. The first, the grand prize, will go to the hygienist who sends
            the most documented calls to the Helpline within a year. The second prize will go to the CDHA
            district that first documents that every one of its hygienists (whether CDHA members or not)
            have given a gold card to a smoker.

         Established fax and healthcare referral systems utilize several different methods for promoting their
     services to providers and patients. For example, New York uses their cessation center partners to
     “spread the word.” These partners have established relationships with healthcare institutions through
     their work to encourage adoption of the Public Health Service guideline on treating tobacco dependence.
     New York has found value in including promotion of the fax referral system as part of a larger
     conversation on systems change to support tobacco cessation interventions.
         Wisconsin has taken a similar approach and uses six Regional Outreach Specialists who go into
     clinics, hospitals, worksites and health systems and assist staff in becoming a Fax To Quit site. The

18   Quitline Operations: A Practical Guide to Promising Approaches
                                                                                                           Chapter 2

Regional Outreach Specialists also provide ongoing technical support to Fax to Quit sites to increase
success of the program by training new people when there is staff turnover, answering program-related
questions and sending feedback reports. Wisconsin has developed a Fax to Quit FAQs brochure for
providers and patients. (See Appendix C for the Fax to Quit FAQs brochure for providers and Appendix D for the
Fax to Quit FAQs brochure for patients.)

    The State of Washington partners with local health department staff to promote the quitline to
healthcare providers. The state tobacco prevention and control program pays for the promotional items
(a video produced specifically for providers to show exactly what happens when a person calls the
quitline and quitline notecubes, pens, posters, business cards, card holders and magnets all designed
with providers in mind). Local tobacco staff use these items to “get in the door” and begin the
conversation with practices, as give-aways to providers during partnership meetings, and as a tool
during trainings on the brief intervention. Local tobacco partners were provided training on how to
work with providers and practice staff when the outreach effort was launched. These activities, along
with state-sponsored brief intervention training to healthcare providers, have resulted in a marked
increase in the number of calls to the quitline in which a caller reports hearing about the quitline from a
healthcare professional.
    Working with regional or state-level medical associations is also a way to promote referral systems.
Grand rounds, dinner meetings, offering trainings and CME/CEU credits and individual meetings with
providers are all important potential avenues for encouraging participation in referral programs and
support of the quitline. The key is to be as proactive as possible when launching and maintaining these
types of systems. A mailing to physicians that includes fax referral forms and an explanation of how
the program works is likely to result in far fewer referrals to the quitline than a face-to-face meeting
with the physician and their staff – especially if this meeting (or follow-up meetings) also includes a
discussion on important institutional or systems-level changes that can be made to ultimately better serve
tobacco users in their attempts to quit. And yes, bring food to these meetings!

    Here's a
        When developing fax referral forms, be sure to involve your healthcare partners. They
    may want to have their own logo on the form, or have it “personalized” in some way. As much
    as possible, try to encourage a standardized form and be sure to field test the form before
    “going live.” (See Appendix E for a sample fax referral form from Wisconsin.)

    There are a range of activities geared toward linking quitlines and the medical community in order
to increase call volume throughout the US and Canada. While the purpose and goals of these activities
are similar, the ways in which states and provinces have chosen to build and sustain these partnership
efforts tend to differ based on budget, target population and intended long-term outcomes. Again, there
are few proven practices when it comes to implementation of healthcare and fax referral systems.
However, we continue to learn from our partners and encourage ongoing research that will eventually
establish a stronger evidence base to guide us.

                                                 Quitline Operations: A Practical Guide to Promising Approaches   19
Chapter 2

            Do you need to talk with someone who has experience working with the medical
            community to link providers with the quitline? These people have been there…

            Rob Adsit                                           Connie Revell, MA
            Education and Outreach Programs                     Deputy Director
            Supervisor                                          Smoking Cessation Leadership Center
            UW Center for Tobacco Research and                  University of California, San Francisco
            Intervention                                           415.502.4175
                608-262-7557                                       crevell@medicine.ucsf.edu
                                                                Craig Ryder, MPA
            Nikki George                                        Associate Director
            Smokers’ Helpline Coordinator                       Tobacco Control Program
            The Lung Association of Newfoundland and            New York State Department of Health
            Labrador                                                518.474.1515
               709.726.4664                                         cxr10@health.state.ny.us
                                                                Donna Warner
            Gail Luciano                                        Director of Cessation Initiatives
            Manager                                             Tobacco Control Program
            Smokers’ Helpline                                   Massachusetts Department of Health
            Canadian Cancer Society, Ontario Division               617.624.5912
                905.387.4322, ext. 618                              donna.warner@state.ma.us

20   Quitline Operations: A Practical Guide to Promising Approaches
                                                                           Chapter                   3
                                                  The Minimal Data Set:
                                          Moving Toward Implementation

The idea of proposing a minimal data set (MDS) for tobacco cessation quitlines first arose in June
of 2003 at a strategic planning meeting for the North American Quitline Consortium (NAQC). A
recommendation was made at this meeting to consider a standard approach to evaluation of quitlines,
and as part of this discussion it was suggested that an MDS be developed which would ultimately:
       q   Facilitate learning across quitlines.
       q   Allow for better understanding of quitlines.
       q   Provide consistent measures for comparisons across quitlines.
    As a follow-up to that meeting, NAQC worked with the quitline community and Canadian partners
(Health Canada and the Centre for Behavioral Research in Program Evaluation, University of Waterloo)
to develop a set of indicators for the minimal data set.
       q   A small working group of US and Canadian quitline researchers, service providers and
           funders was formed. The NAQC Research and Evaluation Working Group is co-chaired
           by Sharon Campbell, PhD and Deborah Ossip-Klein, PhD.
       q   Meetings with quitline funders, service providers, providers/operators and researchers
           were held in Ottawa, Canada in September 2003; in Boston, Massachusetts in
           December 2003; at the Society for Research on Nicotine and Tobacco (SRNT) meeting
           in Phoenix, Arizona in February 2004; and San Diego, California in June 2004.
       q   Recommendations after each face-to-face meeting were circulated to all quitline
           stakeholders in the US and Canada for input.
       q   Reviews of existing evaluation frameworks and questions were considered, as well as
           input from the public consultations.

                                                   Quitline Operations: A Practical Guide to Promising Approaches   21
Chapter 3

               q   Presentations were made to the European Network of Quitlines and drafts circulated to
                   Australian quitline researchers for input. The penultimate Minimal Data Set was
                   reviewed by several members of the SRNT as well.

                 Bigger Picture
         The purpose of the MDS is to provide quitline researchers, service providers and funders with a
     standard approach to reporting quitline performance. This will help all of us understand such factors as
     how people hear about quitlines and thus how to improve promotion strategies; and who calls quitlines,
     and whether or not we are reaching our target population of tobacco users. Quitlines are a relatively
     new cessation strategy with most having been developed in the last five years. Everyone is learning
     how best to run these services and without having comparable measures it is hard to learn what works
     best under what circumstances. MDS is designed to be simple, easy to implement and report, and
     provide valid data on a few important indicators.

            from Practice

        The American Cancer Society (ACS) is one of several quitline vendors that has already begun to
     consider how best to implement the MDS for each of their quitline customers.
            ACS will break MDS implementation into three distinct phases:
            Identification: During this first phase, ACS will look
            at their current intake questions and corresponding
            data points and will compare these with the MDS                    Caution
            recommendations. They will create a customized
            spreadsheet for each of their state clients that lists the       The most critical challenge of
            existing question/data point and the MDS recommended         implementation will be the shift from
            question in order to highlight needed revisions.             existing evaluation measures to the
            This process will identify any necessary changes that        MDS questions. Evaluators, funders
            need to be made and give ACS a launching point for           and service providers will want to be
            subsequent discussion with their clients.                    sure how the new MDS questions are
                                                                         analogous to the questions they are
            Comparison: Once ACS has identified all necessary
                                                                         currently asking so that comparisons
            changes that need to be made, they will conduct a
                                                                         to past performance can still be made.
            comparison of current data gathering to reporting and
            also compare existing data to how the reporting will
            change as a result of the MDS recommendations. ACS believes this will be the longest phase and
            take the most time commitment because of the impact on historical comparison of data (an impact
            which is likely very important for state clients to be aware of and fully understand).

22   Quitline Operations: A Practical Guide to Promising Approaches
                                                                                                        Chapter 3

       q   For example, ACS currently collects race/ethnicity information from callers by asking a
           question that is different from the MDS recommended questions on race/ethnicity.
           Currently, Hispanic is a possible response listed under one question on race/ethnicity.
           However, in the MDS, race and ethnicity are split into two questions in order to allow
           comparisons to US Census data. US Census considers Hispanic to be an ethnicity and
           not a race. ACS may see an increase in their Hispanic data point due to this change, but
           this increase may not necessarily mean that more Hispanic callers are using the quitline.
       q   ACS currently reports quit rates through continuous abstinence. The MDS recommended
           quit rate includes point prevalence based on constituents who receive one counseling
           session. ACS will see an increase in their quit rates due to the change in definition of
           constituents who receive one counseling session as opposed to the previously
           utilized denominator of those who chose to receive counseling.
   All variables with a changing data point will be analyzed for projected changes during this phase
   and will continue to be monitored over time. It will also be important to discuss all of this with
   each of their clients.
   Programming and Reporting: Once final decisions and approvals have been given to move forward
   with implementation of the MDS recommendations, ACS will make all programming changes to
   their data collection and reporting environments. They will monitor the changes closely in order to
   report on projected variations in reporting and outcomes for their clients. ACS predicts that there
   will be a transition period where they monitor outcomes and reporting in multiple ways to report on
   these variations.
    Here's a
       As with any implementation planning, it will be important for all stakeholders to remain
   flexible and to “keep their eyes on the prize.” Service providers, funders and evaluators should
   engage in regular communication about implementation progress, challenges and barriers.
   Use www.NAQuitline.org as a resource! There you will find the MDS Implementation
   Toolbox, eBulletins on MDS-related topics and a NAQC Bulletin Board available for questions,
   information exchange and comments/feedback among NAQC members.

    One of the biggest challenges for the Research and Evaluation Working Group was coming up
with a “minimal” data set – one that would capture important information needed for comparison, but
that would not place an undue burden on quitlines. The working group did discuss social-relation
questions and questions related to target populations (e.g., pregnancy, sexual orientation) and
thought that rather than include these types of questions in the minimal data set, they would best be
included in the “optional” category of questions. “Optional” questions will be outlined in the MDS
recommendations with standard wording and standard calculations, so these become comparable across
quitlines as well.

                                              Quitline Operations: A Practical Guide to Promising Approaches   23
Chapter 3

         While we are just now in the early phase of MDS
     implementation, it is important to remember that this                 Caution
     data set is not static. Over the next year, NAQC and the
     Research and Evaluation Working Group will monitor                 The MDS will not tell us which
     issues that arise during initial implementation and a          quitlines are effective, or which ones
     six-month check-in will serve as a way to determine            are more effective than others. It will
     “course corrections” that may be needed. Feedback from
                                                                    provide standard ways of measuring
     all of the stakeholders engaged in this exciting process
                                                                    quit rates, but will not allow definitive
     will be critical to our success. There are sure to be many
                                                                    statements to be made about any
     questions during MDS implementation and NAQC is
                                                                    difference among quit rates.
     committed to continuing its work to provide avenues for
     shared learning and networking, as well as the tools and
     resources you will need to be successful. We are all well on our way to a whole new world of quitline
     evaluation and research…together!

     Timeline for Minimal Data Set (MDS) Implementation and Support Activities
        February 2005
          q NAQC Research and Evaluation Working Group meeting in Phoenix to finalize MDS
          q MDS support documents in progress
          q Communication subgroup formed to work on Communications Strategy for MDS

        February/March 2005
          q Pilot groups test questions (ACS, California, Free and Clear, Canada)
                – Case studies to be developed from pilot programs for presentation at May
                   meeting in Chicago

        March/April 2005
          q E-Bulletin sent to stakeholders with MDS overview and timeline for implementation
          q Q&As distributed on most FAQs about MDS implementation

        April 2005
          q Changes to supporting documents implemented. Distribution copies produced
               – Any changes to materials posted on NAQC Website

        May 2005
          q MDS and supporting documents completed and available for mass distribution
              – Electronic files available on NAQC Website
              – Distributed at NAQC May Annual Meeting in Chicago

24   Quitline Operations: A Practical Guide to Promising Approaches
                                                                                                 Chapter 3

June/August 2005
  q Quitlines adjust, change and test their data collections systems
  q Conference calls and e-Bulletins with stakeholder groups as needed
  q MDS Implementation Toolbox available
  q NAQC Bulletin Board available for questions, information exchange and comments/
    feedback among membership

August/September 2005
  q NAQC Bulletin Board available for questions, information exchange and comments/
    feedback among membership

September 2005
  q Quitlines start MDS collection
  q NAQC Bulletin Board available for information exchange

October/November 2005
  q Mini-survey on MDS implementation process

December 2005
  q NAQC checks-in to see how MDS is working

                                       Quitline Operations: A Practical Guide to Promising Approaches   25
Chapter 3

            The people below may be able to help you with questions related to MDS implementation.

            Brenda Bryan                                        Deborah Ossip-Klein, PhD
            Consultant                                          Director
            North American Quitline Consortium                  Smoking Research Program
               602.234.0826                                     Division of Social and Behavioral Medicine
               naqc2@americanlegacy.org                         University of Rochester School of Medicine
            Sharon Campbell, PhD                                    deborah_ossipklein@urmc.rochester.edu
            Evaluation Studies                                  Joanne Pike, MA, LPC
            University of Waterloo                              Quitline Director
                519.888.4583                                    American Cancer Society
                sharoncm@healthy.uwaterloo.ca                       404.320.3333
            Karen DeLeeuw
            Program Manager
            State Tobacco Education and Prevention
            Colorado Department of Public Health

26   Quitline Operations: A Practical Guide to Promising Approaches
                                                                       Chapter                   4
                                     Promoting Quitline Services:
                                Managing Messages in the Face of
                                               Shifting Budgets

       Bigger Picture
Several different methods are currently being used to promote quitline services.
    From brochures, fact sheets, posters and flyers to radio, television and even online advertising, the
avenues for promoting quitline services are numerous. Of course, for most quitline funders budget is
the most determinant factor in choosing how to promote their quitline. While most would agree that
television is the best method to reach the highest number of tobacco users, its cost typically prohibits
many states and provinces from investing in it to a large degree. In fact, only two quitlines in Canada
are able to run television advertisements.
    Aside from lack of funding for promotion, lack of staff resources and capacity and an inability
to meet service needs resulting from increased promotion are other notable barriers to successfully
promoting quitlines. The result is often a reliance on promotion efforts that are not necessarily believed
to be the most successful, but that are instead the least resource intensive. For example, due to lack of
resources, both monetary and personnel related, West Virginia can only air television and radio spots in
specific parts of the state at one time. West Virginia has had to “cap” the number of people served by
the quitline at 65 per week due to lack of funds. A successful, high frequency mass media campaign
certainly has the potential to generate far more calls than that.
    Although most quitlines do some level of relationship building, the utilization of relationship
building as a promotion strategy has recently become popular due to tightening budgets. Most of these
efforts have been focused on the healthcare community, employers and insurers. The ultimate goal is to
create referral networks so that calls to the quitline are being driven by sources other than mass media
or other, more traditional promotion methods.

                                               Quitline Operations: A Practical Guide to Promising Approaches   27
Chapter 4

            from Practice
         Arizona’s current statewide quitline promotion strategies include print media, radio and television.
     Arizona also specifically diverts mass media dollars to market the quitline to Spanish-speaking
     residents. However, their key promotional effort is based on relationship marketing to promote quitline
     services to healthcare providers, healthcare systems and worksites.
         For Arizona, many of its changes in promotion strategies and messaging have been directly tied to
     budget cuts. In 1994 when the quitline started, there was no budget specifically set aside for media to
     promote the quitline. Over time, dollars were earmarked for both cessation and targeted campaigns
     (such as pregnancy, Spanish-language and secondhand smoke) and all creative was tagged with the
     quitline number. At one time the total program budget was $33 million, however, in 2001 that budget
     was reduced to only $22 million with threats for more reductions aimed at the overall program, including
     the quitline. The state scaled back funding for all services and diverted resources from promotion.
         As expected, the lack of media and promotion resulted in low call volume and staff quickly
     determined that they needed a less costly method to promote quitline services. Relying on relationships
     that had already been established, a proactive referral service was developed to augment services and to
     encourage new relationships with healthcare providers. A fax referral system, along with a collaborative
     effort with local tobacco programs to promote the quitline, has surpassed traditional, high-cost
     promotion efforts as the highest referral source.

                  If implementing a proactive referral system to take the place of or augment high cost
            promotional campaigns, it is important to keep the following in mind:
                  q   This promotional method will result in lower call volume when compared with
                      call volume generated through mass media.
                  q   The dynamics and demographics of the calls are likely to be different.
                      For instance, the majority of calls may no longer be one-call interventions,
                      rather multiple intervention, long-term counseling calls. For Arizona, client
                      demographics shifted as well. Their callers now tend to be increasingly whiter,
                      more of them English-speaking and insured as opposed to callers when mass
                      media was responsible for driving call volume.
                  q   You are also likely to note a difference in callers’ readiness to quit. Those being
                      referred through the proactive referral system may not be as ready to quit as those
                      who call on their own.
                  q   The paperwork and systems needed to manage the referrals bear an
                      administrative cost that should not be overlooked.

28   Quitline Operations: A Practical Guide to Promising Approaches
                                                                                                         Chapter 4

  from Practice
    Arizona has also piloted two “relationship building as a quitline promotion strategy” programs with
WIC offices in their state as an effort to target pregnant and post partum women. The first program
was a contracted relationship between the state health department’s tobacco office and specific WIC clinics
located throughout Arizona. The pilot included training for the WIC Community Nutrition Workers
(CNW) to intervene with tobacco users. Promotional items were created to promote calls to the
quitline. The quitline hired a former CNW to counsel all WIC quitline callers. Unfortunately, this
program did not see an increase in calls from clients who were on WIC despite the training and
promotional brochures and other give-aways used to increase referrals and awareness.
    The second program targeted one of Arizona’s
most disparate, rural and tobacco-using counties by                 Caution
creating a fax referral system that would gain client
consent to have someone from a quit smoking class                Finding a balance of promotion
contact them to explain cessation program options.           strategies is essential – don’t put all of
CNWs from the county’s WIC office gained consent             your quitline promotion eggs in one
and faxed the referral to the community quit smoking         basket so to speak. Even though budgets
class who explained cessation services offered: a            are tight, it is important to remember the
group-based quitting program or telephone-based
                                                             impact of mass media cessation messages
counseling through the quitline. Arizona saw a
                                                             on changing environmental norms about
tremendous increase in the number of WIC referrals
                                                             quitting and their influence on unaided
to the quit smoking class, which then resulted in
referrals to the quitline. Within a year after the pilot,    cessation attempts.
the system was changed to allow proactive referrals
from WIC directly to the quitline, with the quitline explaining services available as opposed to a
quitline referral from the community quit smoking class. Changing the referral so that it comes directly
to the quitline has proven to be a successful promotion strategy for Arizona to market its cessation
services at a statewide level.

     Here's a
   Some states choose to “tag” all tobacco prevention and control messaging with the quitline
   number and others choose not to. It is important to consider the pros and cons of such an approach.
       q   Increased exposure to the quitline number
       q   Potentially cost-efficient if this approach replaces cessation-specific campaign or allows
           for a smaller-scale cessation campaign
       q   Branding or message confusion
       q   Not geared toward appropriate target population

                                               Quitline Operations: A Practical Guide to Promising Approaches   29
Chapter 4

                in Action

         While most quitlines and funders seem to be able to report on the cost per caller in terms of
     delivering the intervention (even broken out by information only vs. intensive counseling), it does not
     look like quitlines or funders have concentrated on determining cost per caller broken out by method
     of promotion as a means to informing their cost-effectiveness evaluation. This is a critically-needed
     addition to the evidence base for quitline promotion best practices.

            from Practice

         The Canadian Network of Smokers’ Helplines has recently embarked on its first promotional
     project as a network. This Health Canada funded project can be broken down into three phases.
         The first phase started in the fall of 2004 and began with the formation of an advisory committee. A
     knowledge synthesis of best practices in quitline promotion was conducted and results of the synthesis
     were presented at a workshop for quitline stakeholders from across Canada. From there, the group was
     asked to reach consensus on issues such as target message, target audience and planning. Stakeholders
     wanted tools developed so that regional quitlines could use them to drive calls to their quitlines;
     thought the target audiences should be those 35 to 55, as well as physicians; and wanted a mass media
     campaign (TV, print and radio, although the project only has enough funding for print and radio) and a
     toolkit for healthcare providers.
         The effort is currently in the second phase – the project execution phase. This phase involves
     concept and creative development and research to test both new and existing creative, as well as best
     dissemination methods for toolkits for healthcare providers.
         Phase three is the dissemination and evaluation phase of the promotional effort. While there is not
     funding to do an extensive media buy, the project will disseminate all creative templates that are
     developed to the provincial quitlines to distribute locally. A small national media buy (ad and shrink-
     wrapping kits in a professional healthcare journal) will be purchased to supplement regional distribution
     of the kits to healthcare providers. In addition, a web site is being developed to help disseminate
     materials in the future, as is a training workshop for quitline providers to assist them in working with
     their media agencies and learning strategies for securing earned (free) media. As there will be no significant
     media purchase at this time, evaluation will be limited to the development and implementation of a
     data tracking mechanism to track results by region for future evaluation and a stakeholder survey.
        While the life of their project has been relatively short, the Canadian Network of Smokers’
     Helpline’s learning in regard to managing promotional messages in the face of shifting budgets have
     been great:
              q   Partnerships are critical and beneficial – they often result in sharing dollars and
                  sharing wisdom.
              q   There is a great need for clear objectives, defined targets and integrated messaging.

30   Quitline Operations: A Practical Guide to Promising Approaches
                                                                                                      Chapter 4

   q    Integrated campaigns are important for increasing the impact of the dollars.
   q    Evaluation is essential if we are to inform best practices in promotion of quitline

Here's a
       Here are some potential barriers and solutions to keep in mind when developing a
multi-partner promotional effort:

Barrier     Finding a balance between time spent coordinating with partners and trying to
            deliver a product quickly and according to timeline.
Solution    Be clear from the beginning about the review/input/feedback process that will be
            followed and even consider formally writing this down. Create a norm that is
            respectful of deadlines – having the group agree that if a deadline passes and
            feedback is not received, it is okay to move forward according to timeline in order
            to keep the process on track.

Barrier     Partners with diverse objectives.
Solution    Encourage recognition that all partners are working toward the same purpose –
            getting people to quit. Ultimately the entire group is trying to drive cessation even
            though they might have different ideas about how best to get there. Remind the
            group of the bigger picture often and give recognition to partners who show an
            ability to put aside their own agenda to focus on the larger vision.

Barrier     Short-term versus long-term funding.
Solution    If your promotion partnership is a project, rather than an ongoing, long-term funded
            program, it is important to be upfront about this. Being honest about the dollars is
            always a good idea – especially as it relates to building trust among partners. It is
            also important to consider developing promotional items that will have a life beyond
            that of the funded project. How are your tools going to be sustainable? Is some level
            of sustainability possible, or even important, to the group?

Barrier     Partners with varying budgets or varying degrees of ownership of the project.
Solution    It is true that some partners will bring nothing to the table other than an interest to
            help. It is also true that some partners will be at the table because they were told they
            had to be there. Partners who are contributing more dollars than others are likely to

                                            Quitline Operations: A Practical Guide to Promising Approaches   31
Chapter 4

                       expect to have more “say” in development and implementation. This is where
                       clearly defined roles and expectations are helpful – as is accountability. Being
                       upfront about how decisions will be made (by voting; using a consensus model;
                       feedback to decisions made by authority only) from the very beginning will likely
                       alleviate breakdowns in communication or bruised egos. While partners’ contributions
                       may look different, always come back to why you convened the group in the first
                       place – to find a way to best promote the quitline to the largest number of people in
                       the most cost-efficient way. Bringing the group back to this purpose when things get
                       tough can be helpful.

                Balancing the frequency of promotion with the capacity of the quitline to respond to a
            sudden or prolonged increase in call volume can be difficult. However, most quitline service
            providers have learned valuable lessons from past experiences and are more than likely able to
            give important insight into approaching this sometimes fine line. For this reason, it is critical
            that the quitline contract manager, the quitline service provider and the media firm responsible
            for media purchasing are in close communication throughout campaign planning and launching.
            When it’s all over, a debriefing meeting can be helpful to identify glitches in communication,
            problem-solve for future efforts and, of course, give praise for a job well done.

            from Practice
         Did you know that a recent study from Stanford indicates that 70 to 75% of all Americans have
     access to the Internet at home and/or work? For this and other reasons, online advertising as a way to
     promote tobacco cessation programs is gaining popularity, especially among those quitlines that are
     also piloting or funding a web-based component.
               The following description was written by Pat Milner, Product Developer, QuitNet
                   QuitNet worked with the Colorado Department of Public Health and Environment
               throughout 2004 to test online advertising as a way to drive traffic to and enrollment in
               the Colorado QuitNet and the Colorado Quitline. While the bulk of the campaign
               emphasized the ability to recruit Colorado QuitNet members, it also tested the feasibility
               of recruiting Colorado Quitline participants.

32   Quitline Operations: A Practical Guide to Promising Approaches
                                                                                                          Chapter 4

    To test the effectiveness and cost of online advertising, QuitNet managed a campaign on behalf of
the Colorado Department of Public Health and Environment during the Summer and Fall of 2004. A
series of ads, with a variety of creative, were placed on six web sites (Google, Yahoo, Denver Post,
CBS4, MSN and AOL) to encourage enrollment in the Colorado QuitNet and the Colorado Quitline.
The response to these ads was tracked in order to determine their effectiveness in recruiting new
visitors and registrants and the cost per enrollee. The results indicate that online advertising is a highly
cost-effective way to promote cessation services. In this particular case study, the average cost per
registrant/referral was less than half of the CDC estimate of approximately $175 to $225 per enrollee
for traditional offline promotion such as TV, radio, billboards, etc.
    The benefits of Online Advertising vs. Traditional Advertising as seen in the Colorado Case Study
are as follows:
       q   Ability to know the exact cost of “acquiring” a new enrollee: Unlike offline
           advertising, ads placed online can be tracked through to registration and beyond,
           providing an accurate cost of gaining a new participant in the quitline.
       q   Cost effectiveness: The Colorado case study suggests that use of online advertising is a
           cost-effective way of recruiting people to quitline programs.
       q   Flexibility: In the offline advertising world, it is necessary to decide on the final ad
           prior to launching the campaign. With online advertising testing can be done in a live
           setting. An instant view of the results allows for the switching out of under-performing
           advertising and replacement with new ads. This can be done as frequently as every few
           days or every week.
       q   Tracking: It is possible to track every single ad placement on every web site used.
           Each ad can be assigned a tracking link that can be analyzed in terms of the click-
           through rate (number of people that clicked on the ad) and the conversion rate (the
           percentage of site visitors that completed registration). Tracking can continue all the
           way through follow-up surveys. This provides insight into the cost-effectiveness of one
           placement over another.
       q   Testing: It is possible to test different creative designs against each other and to
           measure success by the click-through rates received. Also, different designs attract
           different demographic characteristics and this is all able to be reported using the
           registration data of new users from each of the creative concepts (ads) used.
       q   Reach: Online advertising can reach a very large number of people when they are
           looking for help with quitting. According to a study conducted by the Pew Internet &
           American Life Project in 2003, six million people a year look for quitting assistance on
           the Internet. Online advertising offers a terrific opportunity to reach smokers when they
           are ready to quit and need help. Online advertising can be “geo-targeted” by state, so
           only smokers from your state will see the ad for your state.

                                                Quitline Operations: A Practical Guide to Promising Approaches   33
Chapter 4

34   Quitline Operations: A Practical Guide to Promising Approaches
                                                                                                         Chapter 4

    Here's a
   When planning a promotional campaign, it is vital to establish an evaluation plan.
       q   How will you know if the campaign is successful?
       q   How resource intensive will the evaluation of the campaign be?
       q   What are some of the likely unintended outcomes that you will count as success?
       q   What does an unsuccessful campaign look like?
       q   If you aren’t getting the results you wanted, are you willing to take a step back and
           possibly rework the entire campaign?
       q   Most quitlines evaluate promotion using call volume, “how heard about” and source
           of referrals as indicators. What indicators will you use? Are there others that might
           indicate the message and/or the delivery method is working?

    Each quitline varies in terms of the type and intensity of promotion, promotion expertise available
and ability to work in partnership depending on their budget, where they are housed, the nature of the
staff employed and the level of integration with state or provincial comprehensive tobacco control
strategies. While over the years we have learned a great deal about the types of messages that work
and don’t work with tobacco users and the importance of integrating social marketing strategies with
more traditional marketing concepts, we have much more to learn about the cost-efficiency of each
promotion method, partnering to integrate campaigns and creating sustainable approaches as dollars
dwindle. For these reasons, continued collaboration on quitline promotion strategies between funders,
service providers and researchers is necessary.

                                               Quitline Operations: A Practical Guide to Promising Approaches   35
Chapter 4

            Starting to think about innovative promotion approaches? The experts below welcome
            your questions.

            Kathy Danberry                                      Dave Robertson-Palmer
            Cessation Program Manager                           Program Officer
            West Virginia Division of Tobacco Prevention        Office of Programs and Mass Media
                304.558.6260                                    Tobacco Control Programme
                kathydanberry@wvdhhr.org                            Health Canada
            Karen Fainman
            Marketing Manager                                   Bec Ruiz-McGill
            Canadian Network of Smokers’ Helplines              Cessation Unit Director
               416.934.5655                                     Arizona Smokers' Helpline
               kfainman@cancer.ca                               University of Arizona
                                                                    520.318.7212, ext. 209
            Kay Paine                                               rrmcgill@u.arizona.edu
            Partner Development

36   Quitline Operations: A Practical Guide to Promising Approaches
                                                                       Chapter                   5
                        Making the Most of Quitline Resources
                          Through Public-Private Partnerships

As federal, state, provincial and local budgets throughout the US and Canada tighten, many public
agencies are looking for innovative ways to bring together the resources and expertise that are needed
to sustain important public health programs. In many cases, developing and maintaining partnerships
with natural allies, as well as not-so-natural allies, has been the vehicle to do just that.
    When a partnership exists between the public sector and the private sector in order to attain a shared
goal, this is called a public-private partnership. These partnerships are a direct response to the question
“How best can we leverage the resources available to do this work?” Tobacco prevention and control
programs are quickly learning the value of these partnerships and the potential for cooperation between
these sectors on both the policy and operational fronts – especially as they relate to quitlines.
Partnerships are formed to improve quality, increase utilization and promote better access to quitline
services, and while each partnership is unique, they share some common characteristics:
       q   The partnership exists between organizations from both sectors.
       q   Partners are working toward a SHARED goal or objective.
       q   Each partner is contributing something to the effort (money, expertise, time, space, etc.)
       q   There is shared responsibility for decision-making and management among all

                                               Quitline Operations: A Practical Guide to Promising Approaches   37
Chapter 5

            from Practice

         To meet the needs of Minnesotans who use tobacco, the Minnesota Partnership for Action Against
     Tobacco (MPAAT) partners with seven major Minnesota health plans that are invested in providing
     telephone quitline services to their members. The MPAAT quitline (QUITPLANSM Helpline),
     serviced by Free & Clear, Inc., provides a triage function whereby health plan members that call the
     QUITPLAN Helpline number are warm-transferred to the quitline program administered by their health
     plan. Basically, this transferring of partner health plan members avoids duplication of services and
     allows health plans to serve their members – a perfect example of public sector resources being
     reserved for those without access to services.
            The benefits of MPAAT’s partnership with the health plans include:
               q   Allowing MPAAT to achieve its goals
                      – To serve the uninsured and underinsured.
                      – To avoid duplicating or substituting for benefits available through health plans.
               q   Allowing the health plans to:
                      – serve their own members;
                      – provide more cessation aides to members with benefits, e.g. prescription nicotine
                        replacement products and/or bupropion;
                      – offer coordination with primary care providers during cessation attempts.
               q   Provides access for all Minnesotans to helpline cessation and nicotine replacement
                   therapy (NRT).
               q   Promotes systems changes within health plans to work toward consistency of benefits.
               q   Benefits both the health plans’ and MPAAT’s quitline utilization through multiple
                   marketing campaigns.
         While the warm transfer of health plan members to their health plans’ quitlines appears seamless to
     the callers, there are behind the scenes complexities that quitline vendors must be willing to support.
     The vendor may be called on to engage in forging new working relationships with health plan leaders;
     to influence decisions regarding services; and to foster systematic coordination between the publicly-
     funded quitline and the health plan phone-based or in-person treatment services. There are processes,
     systems, reporting structures and personnel that must be continually enhanced in order to make this
     particular approach to public-private partnership viable. Vendors must be flexible and able to rapidly
     adapt to changes in funding levels, political climate, publicity and even eligibility requirements.
     MPAAT’s public-private partnership illustrates the important role that quitline service providers can
     play in supporting this work.

38   Quitline Operations: A Practical Guide to Promising Approaches
                                                                                                          Chapter 5

    Here's a
      It is seldom true that there are enough public funds to support a tobacco quitline to serve
   everyone. Below are insights on public-private partnerships gained from the Minnesota
       q   The ultimate outcome of this work is that more tobacco users can be served.
       q   It is not unrealistic to partner with health plans considering the benefits they
           realize when their members or employees quit using tobacco – not to mention their
           responsibility to serve their clients or employees.
       q   Public-private partnerships can also stabilize long-term funding for tobacco cessation.
           As we all know, public dollars are constantly at risk. Private-sector resources tend to be
           more stable and available for extended periods of time.
       q   Private partners can help to influence legislative bodies to continue funding tobacco
           treatment services and/or other tobacco-related initiatives. In a sense, overall capacity is
           improved when these partnerships are formed and maintained over time. These partners
           can become great advocates for this purpose.
       q   Private-public partnerships can result in the freeing-up of public dollars, so they can be
           reserved for service provision to those without access to other assistance (for example,
           the uninsured). Essentially, those without access are provided tobacco treatment
           services with public sector resources, while those with access can depend on private
           sector resources.

  from Practice
    While the State of Vermont does not have health plans that are interested in providing telephone
counseling to their members like Minnesota, health plans in Vermont have entered into a limited
partnership with the Vermont Department of Health (DOH).
    The three major insurance companies in Vermont offer discounted NRT to their fully-insured
members. The DOH helps administer this program through a network of cessation counselors in each
of the 14 hospitals in the state. Health plan members who call the quitline can go to their local hospital
and receive a voucher for NRT to be redeemed at a participating pharmacy. Health plan members are
eligible for a total of 10 weeks of NRT with a $20 co-pay every two weeks. These insurance companies
are also providing a limited amount of provider education on Vermont cessation services, as well as
getting information out to their members on the benefit offered for quitting assistance. This partnership
with the health plans, along with the NRT distributed through the quitline to the uninsured, Medicare
members, and Vermonters enrolled in one of the DOH’s “Healthy Vermonters” initiatives, covers 75%
of tobacco-using residents.

                                                Quitline Operations: A Practical Guide to Promising Approaches   39
Chapter 5

         While this partnership results in improving access to NRT for health plan members, Vermont has
     identified several drawbacks to this system:
               q   Counselors at the hospital have to go through a cumbersome pre-approval system in
                   order to provide a voucher to a health plan member.
               q   Health plans do not provide coverage for their self-insured members, thus creating a
                   multi-layered system.
               q   Billing is not completed at the pharmacy level. Instead, the pharmacy submits the
                   voucher to a central location at the Vermont hospital under contract to administer
                   this benefit. This hospital reimburses the pharmacy, and then the hospital must seek
                   reimbursement from the health plan.
               q   Awareness of this program is low.
               q   Only 70% of vouchers are ever redeemed.
               q   The $20 co-pay is a barrier to access.
               q   Members must make multiple trips to obtain the NRT over the course of their quit

             Here's a
                To many states, the number of potential health plans to work with may seem overwhelming.
            Don’t let it be! Take some time to identify the top two or three plans in your state (perhaps those
            serving the most members or even those serving the most tobacco users), and start there. These
            companies are in competition with one another for business and you can bet that if one begins to
            offer a robust service to its members, the others are likely to follow suit.
                Don’t be discouraged by “false starts” – not every health plan is ready for this discussion.
            Just like a tobacco user learns from every quit attempt, there are valuable lessons learned in
            every false start!

                 It is true that health plans and employers may have little incentive to participate in a
            partnership related to tobacco cessation. Perhaps a state or province is already using public funds
            to provide robust cessation treatment to ALL quitline callers. In this case, health plans and
            employers may choose to refer their members and employees to the quitline, thereby abdicating
            their responsibility to fund such services. This barrier to partnerships with these entities can be
            reduced by triaging quitline services. For example, provide all callers with a single intervention
            but limit intensive proactive counseling and NRT to those who are uninsured. This model makes
            it easier to convince health plans and employers to join in, as their benefit will offer more
            assistance than the quitline, increase their members’ and employees’ quitting success and
            ultimately, result in cost savings for them.

40   Quitline Operations: A Practical Guide to Promising Approaches
                                                                                                         Chapter 5

        Bigger Picture
    While a great deal of our work in tobacco cessation rests on our ability to sustain partnerships and
our history of doing so, it can be important to remind ourselves of the principles that guide success
when it comes to working with others:
Clear Goals
    Having clear partnership goals not only helps to guide partners through challenges if work gets off
track, they also ensure clarity and allow partners to easily recognize when results have been achieved.
Measure Success
    Don’t only measure success at the end of a project. Continually monitor your results, so there are no
surprises in the end. This way, you will be able to make necessary adjustments mid-stream to ensure the
partnership effort is as effective as it can be.
Include Key Stakeholders from the Beginning
    Don’t go to meetings with prescriptive ideas about how your partners should do things or what kind
of service they should offer. Instead, share data and experiences and work together to identify what
your, and their, constituents need.
Loud Champions
    The more powerful and vocal the champion, the better. Success requires that leaders in partner
organizations are on-board, act as change-agents, communicate the goals of the partnership internally
AND externally and make the partnership visible to the public. It is important to keep working at
getting to who can do what (worker bees vs. authority) and remember...a single approach cannot be
applied to every partner.
Clear Roles and Responsibilities
    Successful partnership management is essential and clear roles and responsibilities are the cornerstone.
How will the partnership govern itself? How will decisions be made? Make sure that partners understand
these facets of governance and they accept their roles. Don’t make assumptions and don’t just get to
work without approaching these critical questions – they may be difficult to do, but not addressing
them may lead to even messier difficulties down the road.
Ground Rules
    Decision making. Conducting meetings. How you will communicate with one another. How you
will share information. Establish and adhere to mutually-agreed upon ground rules.
    Partners must be willing to respond to changing needs and emerging opportunities. Remaining
flexible is critical.
Draw on Partner Strengths and Contributions
    One of the many benefits of partnerships in general, and public-private partnerships in particular, is
the ability to draw on diverse resources, strengths and expertise.

                                               Quitline Operations: A Practical Guide to Promising Approaches   41
Chapter 5

            from Practice

         The North Carolina Health and Wellness Trust Fund (HWTF) is an organization formed after the
     1998 Master Settlement Agreement (MSA) that receives 25% of North Carolina MSA funds. The goal
     of HWTF is “to invest in programs and partnerships to address access, prevention, education and
     research that help all North Carolinians achieve better health.”
         In February 2005, HWTF announced the availability of $800,000 to provide tobacco quit line
     services to North Carolina teens and young adults. Given the North Carolina Tobacco Prevention and
     Control Branch’s (TPCB) efforts already underway for an adult-focused tobacco quitline funded at
     $300,000, HWTF and TPCB developed a partnership and issued a joint Request for Applications (RFA)
     to potential vendors across the country to operate a free, proactive statewide tobacco cessation quitline
     capable of addressing cessation needs of adult, young adult and teen tobacco users.
         The HWTF brings resources, visibility and state-level leadership to the quitline and to the partnership
     with TPCB. By statute, HWTF’s members are representatives of public health, healthcare delivery
     systems, practitioners, researchers, health promotion and disease prevention (including tobacco), health
     policy, underserved populations and child healthcare. On the other hand, the TPCB brings expertise in
     evidence-based tobacco prevention and cessation to the partnership. For example, the Branch, through
     an American Legacy Foundation grant that matched CDC funds to promote the quitline, has a Medical
     Director on staff who has a strong expertise in tobacco use treatment. This partnership is a perfect
     example of drawing upon diverse strengths and contributions in order to make the quitline more effective.
     Maintain Momentum
         There is nothing worse than being part of a partnership project that has stalled. You are meeting for
     the sake of meeting, nothing is going according to timeline and interest in moving forward is waning.
     You must plan for how you will maintain momentum and sustain your efforts – even when the going
     gets rough. Establishing shared ownership in the process of moving forward can help with this.
     Celebrate Success
         One of the best ways to maintain momentum and solidify working relationships is to take some
     time to celebrate success. No matter how big or small, make an effort to show appreciation for
     risk-taking, going the extra mile or simply coming to consensus over a hot-button issue.
         The critical forging of public and private resources in order to ensure the availability of quitline
     services for everyone will not look the same for each state or province – one size does not fit all when
     it comes to partnering with the private sector. Each approach will be different, look different, feel
     different and result in different outcomes. While to this point the public-private partnerships forged in
     the quitline world have mostly focused on health plans and employers, there may be other areas to
     explore in order to continue to ensure the most efficient use of public funds to help tobacco users quit.

42   Quitline Operations: A Practical Guide to Promising Approaches
                                                                                                    Chapter 5

It can be hard to know where to begin in establishing a public-private partnership. A good
first step may be contacting one of the experienced partners below.

Rachel Grossman                                     Randi Lachter, MPH
Manager                                             Intervention Program Manager
Market Development                                  Minnesota Partnership for Action Against
Free & Clear, Inc.                                  Tobacco (MPAAT)
   206.988.7925                                         952.767.1412
   rachel.grossman@freeclear.com                        rlachter@mpaat.org

Todd Hill, LiCSW, LADC                              Ann Wendling, MD, MPH
Tobacco Specialist (Cessation Programs)             Director of Intervention Programs
Vermont Department of Health                        Minnesota Partnership for Action on
   (802) 863-7359                                   Tobacco
   THill@vdh.state.vt.us                                952.767.1411
Jana Johnson, MD, MPH
Medical Director
Tobacco Prevention and Control Branch
Division of Public Health
North Carolina Department of Health and
Human Services

                                          Quitline Operations: A Practical Guide to Promising Approaches   43
Chapter 5

44   Quitline Operations: A Practical Guide to Promising Approaches
                                                                       Chapter                   6
                                            Reaching Priority Populations
                                                   with Quitline Services

    Finding ways to increase priority populations’ access to quitline services is fast becoming a
significant element of tobacco prevention and control efforts. As state and provincial quitlines work to
reach those most affected by tobacco use, the use of lessons learned from traditional outreach methods
in combination with community-based outreach principles is proving to be an invaluable approach.
    Priority populations are typically those communities with a higher prevalence of tobacco use; more
tobacco-related diseases; have less access to treatment; are specifically and disproportionately targeted
by the tobacco industry; have less awareness of the risks associated with tobacco use; and experience a
greater social acceptability of tobacco. Priority populations can include specific racial or ethnic groups,
although they can also be defined more broadly. For instance, some states and provinces choose to
target pregnant and post-partum women; the Lesbian, Gay, Bisexual and Transgendered (LGBT)
community; rural residents; low-income community members or the mentally ill. Each quitline funder
must determine the characteristics they will use to identify their priority populations, as well as the
extent to which they will focus specific outreach efforts on those communities.
    According to Judith Mills, Outreach Coordinator for the California Smokers’ Helpine, effective
tobacco cessation outreach to priority populations:
       q   Develops a presence in the community being targeted.
       q   Raises awareness of the health risks associated with tobacco use.
       q   Increases the awareness and use of the quitline.
       q   Increases quit attempts by members of the target population.
       q   Decreases prevalence of tobacco use.
       q   Changes norms associated with smoking and quitting.

                                               Quitline Operations: A Practical Guide to Promising Approaches   45
Chapter 6

             Here's a
                Before embarking on a targeted quitline outreach effort in a specific community, the
            following questions are important to consider:
                  q     Are you willing to invest in the community over the long haul?
                  q     Is the community ready to hear a cessation message, and if so, what message will
                        resonate most with those who use tobacco?
                  q     What relationship does your organization already have with that community? Are
                        there historical barriers that will need to be overcome?
                  q     If tobacco cessation is not a community priority, are you willing to invest time and
                        energy in helping them to address what is a priority in order to establish relationships,
                        trust and credibility? (Consider the possibility that helping a community to address
                        underlying conditions that create a climate where tobacco use is acceptable or
                        encouraged may be a valuable use of resources, although not typically a strategy
                        found in our tobacco prevention and control “textbooks.”)
                  q     While you may bring tobacco cessation wisdom to the community, your community
                        partners carry expertise that you do not have. They know their membership. They
                        know the likely advocates and the likely barriers. They are aware of the values
                        and beliefs that will help or hinder your efforts. They also know how best to get
                        things done. Are you ready to accept the expertise and leadership of community
                        partners? Are you ready to engage in true dialogue in order to learn how best to
                        promote the services of the quitline?

            from Practice

         The American Cancer Society, as the service provider for the State of Delaware, leverages their
     relationship with Lutheran Community Services (LCS) in order to improve their outreach access to
     low-income tobacco users in that state. LCS works with Delaware’s low-income population on a daily
     basis by providing resources for shelter and administering several local food bank drop-off sites.
     Frequently, ACS will send quitline outreach workers to the local food drops to provide information and
     resources to clients. ACS has also used maps provided by the National Cancer Institute’s Cancer
     Information Service that reflect the highest tobacco use areas in each of Delaware’s counties. The maps
     provide target zip codes for “on-the-ground” outreach at places such as Wal-Marts, bowling alleys and
     local malls.

46   Quitline Operations: A Practical Guide to Promising Approaches
                                                                                                       Chapter 6

        Bigger Picture
    Great importance lies in developing a presence in each community you are targeting, as well as
remaining present in that community in order to build credibility. Throughout history, governmental
agencies have been known to ride into town
with the intention to improve the health of
disparate communities and shortly thereafter             Caution
“cut and run” when the going got tough or
the dollars ran out. There have also been             Being prescriptive to community is one of the
instances of heinous medical procedures,         worst choices you can make when developing and
experiments and policies committed against       implementing a targeted promotional campaign.
communities of color and other marginalized      Some states have established advisory boards for
communities. These events have a history         each of their priority populations in order to have
deeply rooted in the conscience of these         a formal body from which to gather input, seek
communities and are in many ways the root        advice and request feedback. An advisory board
of distrust of government in general and         comprised of diverse members from within a
healthcare in particular. What does this mean    community can provide a breadth of perspectives
for your organization? It means that you         that would otherwise be difficult to gather. An
will need to listen more than you speak –        added benefit of advisory boards is that members
especially in the beginning – and you might      serve as conduits directly back into the community
not always like what you hear.                   – outreach specialists in their own right.

   from Practice
    Delivering the “right” message for a particular community is vital. The California Smokers’
Helpline discovered the degree to which the message being delivered can impact a community through
their initial Asian language advertising campaign. The original campaign resulted in very few calls to
the Helpline’s Asian Language lines. A decision was made to step back and investigate methods of
revising the message in order to increase use of the Asian language services. The advertising agency
spent important time with the Helpline’s Asian language counselors to learn more about the clients they
serve, and a new message was created that reflected the exchange of ideas. The original campaign
encouraged smokers to call and receive counseling to help them quit. The new campaign encouraged
smokers to call and receive help over the phone and information about quitting. The change from
“counseling” to “help” was based on the realization that counseling was considered a mental health
service in these communities, and as such was taboo. A noticeable increase in calls was noted after the
message was changed. The following table illustrates this increase.

                                             Quitline Operations: A Practical Guide to Promising Approaches   47
Chapter 6

     (Note: AAPI/E = English speaking AAPIs and AAPI/A = Asian language speaking AAPIs)

         Another important element to successfully embarking on outreach efforts with priority populations
     is ensuring that the services you are promoting on the front end match the service being delivered on
     the back end. In other words, the promises you make while promoting the services in the community
     must be kept. If they are not, you stand to lose the most vital piece of the community-based outreach
     puzzle – credibility.

            from Practice
         The Washington Department of Health (DOH) currently funds community-based contractors in the
     urban Indian, African-American, Asian-American/Pacific Islander, Hispanic and LGBT communities to
     serve as DOH’s link to their identified priority populations. As each community-based contractor
     worked with DOH to write a plan for addressing tobacco prevention and cessation in their respective
     communities, DOH heard repeatedly that the quitline was not an appropriate resource for many of
     them. There seemed to be a distrust of the line, assumptions about its ability to truly “work” and an
     unawareness of what really happens when a person calls to receive help.
         In response to these comments, a meeting was initiated by the quitline as a way to improve services
     and was facilitated by DOH as a way to break down barriers. It is important to DOH as the quitline
     funder that these community-based contractors feel confident in the quitline’s ability to provide an
     effective service, so they in turn promote the service to their community members.

48   Quitline Operations: A Practical Guide to Promising Approaches
                                                                                                         Chapter 6

    The meeting was convened and lasted for an hour and a half and concluded with a tour of the quitline
facility. Information was shared by both the service provider and by the community contractors. The
meeting created an opportunity for open dialogue with quitline staff and a chance to ask questions and
to hear what really happens during an intervention. By touring the quitline and meeting and hearing
from staff, skeptics of the quitline turned to champions who are now more likely to go back to their
community and promote the service with confidence. The open conversation began to build trust in the
service and those delivering it, and community contractors genuinely felt heard.
   Both sides, the community contractors and the quitline provider, really gained from this meeting
and they plan to continue discussions. Outcomes of the meeting include:
       q   Quitline staff receiving training on cultural issues (in some cases by community
       q   Ongoing discussions about how the quitline can be linked with community-based
           cessation services
       q   Increased attention to the Spanish-language line
       q   Quitline service provider increasing the number of diverse staff
       q   Quitline service provider reviewing data-density issues
   While this meeting was a first step, it was an important one in order for Washington to find ways to
engage in meaningful quitline outreach with their priority populations.

    Here's a
       Don’t have funding to support an outreach specialist or contracts with agencies in priority
   populations? Get creative! Find an organization that does employ an outreach specialist and pick
   their brain. Spend some time with them getting to know their processes and key contacts in the
   community. Ask to observe a few meetings or read through reports they have generated. Most
   importantly, get out from behind your desk! You have to get out there – you can’t do outreach
   or develop a promotional campaign via email.

    from Practice

    The Wyoming Families Matter Project (WFM) is a pilot program based in one county in Wyoming
and falls under the umbrella of the Wyoming Quit Tobacco Program (WQTP). This program offers
social support and incentives to pregnant women who want to quit tobacco and links participants with
the Wyoming quitline or QuitNet in order to do so. Pregnant women who want to quit can enroll in the
program through referral from healthcare providers or by sending in Business Reply Cards (BRC) that
are found throughout the community.

                                               Quitline Operations: A Practical Guide to Promising Approaches   49
Chapter 6

         After enrollment and following a brief intake survey that is conducted by the program’s site manager,
     a participant receives a “welcome packet” within 72 hours, and is linked with a volunteer who will call
     her periodically throughout her pregnancy and through three months post partum. If her physician
     prescribes NRT, the program will offer her a voucher to cover all or part of the cost of the drugs. She
     will be enrolled in counseling either through the quitline or QuitNet.
         While enrolled in the program, a tobacco use test (NicAlert) is administered monthly to participants
     to confirm that they are tobacco-free. Each month that a participant remains quit, she is able to select an
     incentive from a “catalog” that is sent to her within a week of the test. The incentive is typically valued
     at up to $50 each month.
         Pregnant women participating in WFM also have the option of having their significant others
     enroll in the program. Partners receive the same benefits, with the exception of the volunteer calls
     throughout the pregnancy. This program combines social marketing, incentives and support to target
     pregnant women and their partners in an effort to reduce prevalence among one of Wyoming’s target

            The most common barriers to successful outreach to priority populations include:
            q   Lack of trust
            q   Lack of credibility
            q   Limited resources
            q   Limited or no community knowledge and awareness of quitline services
            q   Cessation is often not a priority within the community

        Targeted quitline outreach to priority populations is not an exact science. In fact, to this point it
     remains a mixture of trial and error, a hodgepodge of lessons learned and requires a lot of listening.
     While much good can come from a generalized approach to promoting quitline services to priority
     populations, reasonable efforts to target those communities most impacted by tobacco use should be
     made. In doing so, we know for sure that community input and partnerships are priceless.

50   Quitline Operations: A Practical Guide to Promising Approaches
                                                                                                  Chapter 6

The people listed here have information and insight that may prove useful if you’re just
beginning an outreach effort or if you are facing a challenging roadblock.

Jeanne Chiquoine                                   Charlene Smith
Delaware Tobacco Cessation Manager                 Project Coordinator
South Atlantic Division                            Wyoming Health Resources Network
American Cancer Society                                (307)-635-2930
    302-324-4227                                       CSmith@whrn.org
                                                   Juliet Thompson
Judith Mills, MPH                                  Tobacco Cessation Coordinator
Outreach Coordinator                               Tobacco Prevention and Control Program
California Smokers’ Helpline                       Washington Department of Health
University of California, San Diego                    360 236-3722
    858.300.1012                                       juliet.thompson@doh.wa.gov

                                        Quitline Operations: A Practical Guide to Promising Approaches   51
Chapter 6

52   Quitline Operations: A Practical Guide to Promising Approaches

Quitline Operations: A Practical Guide to Promising Approaches   53

     Quitline Operations: A Practical Guide to Promising Approaches
                                                        Appendix A

Quitline Operations: A Practical Guide to Promising Approaches   A1
Appendix A

                                       TABLE OF CONTENTS

A2   Quitline Operations: A Practical Guide to Promising Approaches
                                                              Appendix A


      Quitline Operations: A Practical Guide to Promising Approaches   A3
Appendix A

                Key findings:

A4   Quitline Operations: A Practical Guide to Promising Approaches
                                                          Appendix A


  Quitline Operations: A Practical Guide to Promising Approaches   A5
Appendix A

               Table 1. Brief Description of the Four NRT Give Away Programs Implemented
               Through the Quitline

A6   Quitline Operations: A Practical Guide to Promising Approaches
                                                           Appendix A


   Quitline Operations: A Practical Guide to Promising Approaches   A7
Appendix A

A8   Quitline Operations: A Practical Guide to Promising Approaches
                                                        Appendix A


Quitline Operations: A Practical Guide to Promising Approaches   A9
Appendix A

A10   Quitline Operations: A Practical Guide to Promising Approaches
                                                         Appendix A

Quitline Operations: A Practical Guide to Promising Approaches   A11
Appendix A

A12   Quitline Operations: A Practical Guide to Promising Approaches
                                                         Appendix A

Quitline Operations: A Practical Guide to Promising Approaches   A13
Appendix A

A14   Quitline Operations: A Practical Guide to Promising Approaches
                                                         Appendix A

Quitline Operations: A Practical Guide to Promising Approaches   A15
Appendix A

A16   Quitline Operations: A Practical Guide to Promising Approaches
                                                         Appendix A

Quitline Operations: A Practical Guide to Promising Approaches   A17
Appendix A

A18   Quitline Operations: A Practical Guide to Promising Approaches
                                                           Appendix A


  Quitline Operations: A Practical Guide to Promising Approaches   A19
Appendix A

A20   Quitline Operations: A Practical Guide to Promising Approaches
                                                           Appendix A


  Quitline Operations: A Practical Guide to Promising Approaches   A21
Appendix A


A22   Quitline Operations: A Practical Guide to Promising Approaches
                                                        Appendix B

Quitline Operations: A Practical Guide to Promising Approaches   B1
Appendix B

                 MIT ROMNEY

                KERRY HEALEY

               RONALD PRESTON



                SPONSORED BY

B2   Quitline Operations: A Practical Guide to Promising Approaches
                                                        Appendix B

Quitline Operations: A Practical Guide to Promising Approaches   B3
Appendix B

             Quitworks for Hospitals and                                                          What QuitWorks Offers
             Health Centers at a Glance
             The Solution to Help Patients Quit Smoking                                           s The state’s proven-effective stop-smoking services—
                                                                                                    proactive telephone counseling, a website, self-help
             QuitWorks is a free, evidence-based stop-smoking                                       information, and referral to community tobacco
             service developed by the Department of Public                                          treatment services
             Health in collaboration with all major health plans                                  s A simple patient enrollment form with HIPAA-
             in Massachusetts. QuitWorks links your patients who                                    compliant patient consent approved by all major
             want to quit smoking to the full range of the state’s                                  commercial and Medicaid health plans
             tobacco treatment services. Using a simple enrollment                                s Patient status reports to referring providers—the
             form, any physician, nurse, or other clinician in your                                 provider you choose will receive faxed information
             hospital or health center can easily and quickly enroll                                on the services each patient selects and, six months
             any patient who uses tobacco, regardless of health                                     later, a report on each patient’s quit status
             insurance status. A QuitWorks team will help you fit the
                                                                                                  s Training for your nurses, physicians, and other
             program to your needs for inpatient or outpatient units.
                                                                                                    clinicians—delivered on site by the University of
                                                                                                    Massachusetts Medical School to introduce your
              “QuitWorks fills a huge gap in the continuity of care we can
                                                                                                    staff to QuitWorks, brief patient motivational
               offer smokers. Hospitals and health centers need to provide
               counseling to smokers after they leave the health care setting.                      interviewing, and the latest pharmacotherapy
               QuitWorks does this with an innovative system that reaches                           dosing guidelines*
               out to contact the patient, offers evidence-based services, and
               keeps the provider in the loop with patient progress reports.”                     s Reports on patient outcomes—aggregate reports
                                                        –Nancy Rigotti, MD                          customized to satisfy JCAHO core measures and
                           Director, Tobacco Research and Treatment Center                          other reporting and research needs *
                 Massachusetts General Hospital and Harvard Medical School
                                                     Boston, Massachusetts                           * At a minimal charge to cover costs

                                                                                        Identify smoker
                                                                                        and document
                                  Receive patient status
                                  reports and aggregate
                                                               5                        smoking status
                                                                                                                         2    Talk with patients
                                                                                                                              about their tobacco use

                                                        Q uit W

                                                                                       Solution                                3   During hospital stay
                                                                                                                                   or outpatient visit, enroll
                                QuitWorks         QW

                                                                                                                                   patient in QuitWorks
                                completes patient

                                assessment and                      ta                                                             Fax enrollment form
                                offers intensive                         ke
                                counseling sessions                           s it
                                                                                     fro m
                                                                                             t h e re …         4    Prescribe medication
                                                                                        Post discharge,
                                                                                        QuitWorks calls
                                                                                        your patient

B4   Quitline Operations: A Practical Guide to Promising Approaches
                                                                                                                                 Appendix B

What You Do—                                                           QuitWorks Takes It
In Five Easy Steps                                                     From There…
1. Set up a system to identify tobacco                                 QW   Calls your patient—Upon receipt of an
   use by patients upon admission, during                                   enrollment form, QuitWorks:
   outpatient visit, during hospital stay,
                                                                            s Conducts a 10-minute telephone
   or prior to discharge.
                                                                               interview to assess readiness to quit
                                                                            s Mails a customized Quit Kit
2. Talk with patients about tobacco use
                                                                            s Offers multiple counseling options
   during hospital stay or outpatient visit,
                                                                            s Advises your patient on course of action
   or prior to discharge, and give the patient
   a “Think About It” pamphlet.                                        QW   Provides intensive counseling services,
                                                                            on the phone or through referral to in-person
3. Complete enrollment form, give
   patient QuitWorks Welcome Guide,                                         s Five proactive telephone counseling sessions
   and fax enrollment form to QuitWorks                                     s Referral to more than 30 community tobacco
   toll-free line.                                                             treatment centers with trained counselors

                                                                       QW   Provides on-line help at www.trytostop.org
4. Prescribe pharmacotherapy, if appropriate,                               s The QuitWizard, a self-directed
   for relief of withdrawal symptoms and to                                    counseling tool
   aid with stopping smoking.
                                                                            s Interactive bulletin board and
                                                                               user community
5. Receive status reports, review, and file                                 s Expert advice and success stories
   in patient medical record.
                                                                            s Access to a warehouse of materials
                                                                               to download to help the patient

 “QuitWorks makes it easy for our busy providers to refer our          QW   Faxes report to referring provider several days
  patients to treatment. Having the materials in Spanish is
  essential for this community. Thank you, QuitWorks!”                      after receiving enrollment form to confirm patient
                                         –Mary Ioven, RN, MA                contact and indicate services selected
                                            Clinical Director
                        Greater Lawrence Family Health Center          QW   Sends a six-month patient quit status report
                                     Lawrence, Massachusetts
                                                                            to the provider identified on the enrollment form;
                                                                            aggregate reports may be customized for your
                                                                            hospital or health center, if desired

                                                                Quitline Operations: A Practical Guide to Promising Approaches         B5
Appendix B

             Getting Started With QuitWorks
             Your Plan for Identifying Smokers and Enrolling Patients in QuitWorks

             Think about integrating QuitWorks in outpatient                       Consider how QuitWorks will fit into admission
             and inpatient units.                                                  forms, medical records, pharmacy, or standing orders
             Use the Guide below to answer key questions,                          at discharge.
             such as:
                                                                                   Think about key players.
                 s How will smokers be identified and                              Bring together a core group of staff, including natural
                   smoking status documented?                                      “champions” from among executive and medical staff,
                 s Who will provide advice to quit and                             quality assurance specialists, nurse administrators,
                   recommend pharmacotherapy?                                      specialists, and unit directors.

                 s Who will complete the QuitWorks                                 Think about how and when to introduce QuitWorks.
                   enrollment form and obtain patient consent?
                                                                                   Will you launch QuitWorks in pilot units, and, if so,
                 s Who will fax the enrollment form?                               which units? Which units see the most smokers?
                                                                                   Will QuitWorks be rolled out institution-wide?

             QuitWorks Implementation Guide for Hospitals and Health Centers
                                                                       WHEN                                 HOW                            WHO
                                    WHAT                      (Suggested Opportunities)             (Suggested Methods)             (Person or Position)

              1. Identify Smoker and Document                 Typically at admission        Nursing or other assessment form        Typically, nurse
                Smoking Status                                or soon after and at          Questionnaire/Survey                    at admission
                                                              every outpatient visit                                                or administrative
                                                                                            Vital signs stamp or sticker            personnel
                                                              Other options: During
                                                                                            Document in medical record for JCAHO
                                                              hospital stay or prior
                                                                                            or quality improvement purposes
                                                              to discharge

              2. Talk with Patient about Tobacco Use          At admission, during          Give patient QuitWorks                  Nurse, physician,
                 • Advise patient to quit                     hospital stay or outpatient   “Think About It” brochure               or other clinician
                                                              visit, or at discharge
                • Assess patient’s readiness to quit
                • Ask if patients would like to be enrolled   Use multiple interventions,
                  in a free program to help them quit         if possible
                • Discuss/Offer pharmacotherapy

              3. Complete Enrollment Form                     During hospital stay or       Give patient QuitWorks                  Nurse, physician,
                 • Include provider information               outpatient visit or prior     “Welcome” brochure                      or other clinician
                                                              to discharge
                • Obtain patient signatures
                • Fax enrollment form to 1-866-560-9113
                  with “call-after date” noted
                • Document that form was faxed and file in
                  patient’s medical record

              4. Prescribe Pharmacotherapy (IF APPROPRIATE)   During hospital stay          See back of enrollment form for         Physician
                 • For relief of withdrawal symptoms          or outpatient visit,          dosing guide; form may be customized
                                                              and at discharge              to indicate medications in hospital
                • For stopping smoking                                                      formulary
              5. Receive Status Reports and Review            Post discharge                • File any status reports sent to the   PCP, referring
                 • Fax back patient status report to                                          hospital in patient medical record    provider, or other
                   provider indicated on enrollment form                                                                            designated personnel
                                                                                            • Compile data for JCAHO and
                • Send optional aggregate reports to                                          quality improvement reports           Quality assurance
                  hospital or health center                                                                                         manager

B6   Quitline Operations: A Practical Guide to Promising Approaches
                                                                                                                                Appendix B

Getting Started With QuitWorks
The QuitWorks Team Will Help Every Step of the Way

To get you started, a QuitWorks team from the               Other customized features are available
Massachusetts Department of Public Health,                  at a small charge to cover costs:
the University of Massachusetts Medical School,             I Aggregate data reporting on smokers you
and the Try-To-STOP TOBACCO Resource                          enroll in QuitWorks, services they receive,
Center is ready to help.
                                                              and quit status at six-months post-treatment

                                                            I Training offered by the University of
Call Us!
                                                              Massachusetts Medical School for your staff
For more information or to schedule a meeting,                on QuitWorks, on how to talk with smokers,
please email Donna Warner, QuitWorks Project                  and on smoking cessation medications
Director, Massachusetts Department of Public
Health at donna.warner@state.ma.us or Beth
Ewy, University of Massachusetts Medical School                            THINK ABOUT
                                                                           THINK ABOUT
at beth.ewy@umassmed.edu. You may also visit                            MEASURING SUCCESS!
                                                                       MEASURING SUCCESS!
www.quitworks.org or www.trytostop.org to
                                                              NN Develop aplan to track who
                                                                Develop a plan to track who
preview our smoking cessation resources.
                                                                   uses QuitWorks in your hospital
                                                                    uses QuitWorks in your hospital.
Schedule the QuitWorks Team to give                           N    Use QuitWorks reports to
                                                                  N Use QuitWorks reports to
a presentation at your facility.                                   track patient enrollments and
                                                                     track patient enrollments and
The QuitWorks Team will come to you and lead a                       patient outcomes by unit within
                                                                   patient outcomes by unit within
one-hour presentation and discussion with your staff               your hospital.
                                                                     your hospital.
on the QuitWorks program and how to customize it              N    Use QuitWorks reports to
                                                                  N Use QuitWorks reports to
for your facility. There is no cost for this session, and          satisfy JCAHO and institutional
                                                                     satisfy JCAHO and institutional
it may qualify for continuing education units.                     performance monitoring.
                                                                     performance monitoring.
                                                              N    Let us know how you’re doing.
Think about customized QuitWorks features.                        N Let us know how you’re doing.
For all participating hospitals and health centers,
we design a customized enrollment form, free
of charge, to help us track enrollment from your
                                                             “The QuitWorks team’s proactive assistance in supporting our
institution and prepare reports for you. We will              hospital-wide tobacco cessation initiative was invaluable. They
put your hospital name and logo on the form                   provided training and educational materials, and customized
and highlight the smoking cessation medications               the QuitWorks enrollment form to suit our institution’s needs.”
available in your formulary. Some institutions                                    Amy Simon, MD and Catherine Milch, MD
                                                                                    Co-Chairs,Tobacco Cessation Initiative
also need additional patient consent language.
                                                                                        Tufts-New England Medical Center
We can help you with this too, and we can provide                                                  Boston, Massachusetts
examples from other hospitals.

                                                   Quitline Operations: A Practical Guide to Promising Approaches                     B7
Appendix B

                Frequently Asked Questions
                Q:   Can anyone enroll in QuitWorks?
                A:   QuitWorks is open to all Massachusetts residents, regardless of health insurance status.

                Q    Is there any cost to the patient or the hospital/health center for QuitWorks services?
                A:   There is no cost to the patient, the referring provider, or the hospital/health center for basic
                     QuitWorks services and materials (fax enrollment, patient counseling services and education
                     materials, patient status reports, and customized QuitWorks enrollment forms). The QuitWorks
                     team will meet with your staff free of charge. However, there is a charge to cover costs for
                     aggregate reports and for training of hospital or health center personnel.

                Q    Is the patient enrollment procedure time consuming?
                A:   No, all you have to do is complete a simple form and fax it to QuitWorks. The form has been
                     endorsed by all major health plans.

                Q    How will I know how the patient is doing in his/her efforts to quit tobacco use once
                     enrolled in QuitWorks?
                A:   QuitWorks will send status reports to the referring clinician, primary care provider, or clinical
                     specialist indicated on the enrollment form. Providers receive two faxes—one within several days
                     of receiving an enrollment form to confirm patient contact and report cessation services selected
                     by the patient, and another at six months to report the patient’s quit attempts and quit status.

                Q    If a patient returns to the hospital or health center at a later date and reveals that
                     he/she has started smoking again but wants to stop, can that patient be re-enrolled
                     in the QuitWorks program?
                A:   Yes, it often takes many attempts to quit smoking. Patients may enroll as many times as they
                     need in order to achieve success.

                Q    Can adolescents benefit from enrollment in the program or is it specifically designed for adults?
                A:   QuitWorks is for all ages, but parental consent is needed for youth under 18 years of age
                     to be enrolled in the program. However, adolescents may call 1-800 TRYTOSTOP or go online
                     at www.trytostop.org without parental consent.

                Q    What kind of assistance will QuitWorks provide in developing a plan and setting up
                     a system for our hospital or health center?
                A:   The QuitWorks team will help from the start, guiding and advising as you put QuitWorks
                     in place. QuitWorks also provides on-site training for your staff and all the materials you
                     will need to implement the program successfully.

B8   Quitline Operations: A Practical Guide to Promising Approaches
                                                                                                                                                                                                                                                                                           Appendix B

     Enroll Your Patients: Three Easy Steps

                                                                                                                        Patient stamp, label, or info. (name, record number/DOB, date)

                                                                                                                                                                                                                                    Customize the Form
                                                                                                                                                                                                                                          • Add hospital
                                                                                                                                                                                                                                            name and logo

              Tobacco Treatment Enrollment
                                                                                                             A Collaboration of the Mass. Department of Public Health & Mass. Health Plans

              Tobacco Treatment Checklist
              ADVISE smoker to stop:                      Stop-smoking advice given: “I strongly advise you to quit smoking and I can help you.”
                                                                                                                                                                                                                                    Helpful Reminders
              ASSESS readiness to quit:                   Ready to quit                              Thinking about quitting                                 Not ready to quit                                                            • Talking with
              ASSIST smoker to quit:                      Brief counseling
                                                          Reasons to quit     Barriers to quitting      Lessons from past quit attempts    Set a quit date, if ready          Enlist social support                                         your patients
1.                                                        Medications if appropriate
                                                          Nicotine Replacement (CIRCLE): patch gum lozenge inhaler nasal spray              Other (CIRCLE): Bupropion (Zyban /Wellbutrin SR )
                                                                                                                                                                                      ®                ®

                                                                                                                                                                                                                                          • Advising on
Provider      ARRANGE follow-up:                          Refer to Try-To-STOP TOBACCO Resource Center
                                                          by faxing the lower part of this form toll-free to 1-866-560-9113                                                                                                                 pharmacotherapy
              Massachusetts Resident Enrollment Form                                                                                 Fax this part of form to 1-866-560-9113
               primary care provider or specialist name                      UPIN# (OPTIONAL)            phone (area code + number)                      fax (area code + number)
                                                                                                         (        )                                      (          )
               primary care provider or specialist address                                               city                                            state                  zip

2.            PATIENT
               first name                                        last name                                                                               date of birth (month/day/year)

Patient        phone (area code + number)                        May we leave a message? language preference (circle):                                   email address

Information    (      )
               patient address
                                                                   yes         no             English
                                                                                                             Spanish other (specify):
                                                                                                                                                         state                  zip

                                                                                                                                                                                                                                    FDA Medications
                                        BCBSMA       BMC HealthNet Plan             Fallon       Harvard Pilgrim       MassHealth       Neighborhood Health Plan (NHP)
                                                          Network Health             Tufts Health Plan        Other_____________________________
                                                                                                                                                                                                                                          • Dosing Guide
              The Resource Center usually calls the patient within three business days of receiving a referral. When should we call?

               circle all that apply:         morning                        afternoon                        evening                     no preference

              I, ___________________________________________________ , hereby authorize Try -To- STOP TOBACCO Resource Center

3.            of Massachusetts,(the “Resource Center”), and its representatives to disclose information about me to:                    Quick Guide To Pharmacotherapy In Tobacco Treatment
                1) the American Cancer Society Quitline to the extent necessary to allow me to participate in its tobacco cessation counseling
                   program; and
Patient                                                                                                  NICOTINE REPLACEMENT OPTIONS
                2) my primary care provider or other provider (“Provider”) I designate to the Resource Center to the extent the
                   Resource Center deems necessary to give my Provider an update of my progress in attempting to stop smoking.
Consent       I authorize NSMC to release the information on this enrollment form to the Resource Center    Nicotrol®
                                                                                                            15 mg
              for purposes of my participation in the QuitWorks program. I also authorize the Resource Center and its representatives to above
                                                                                                                                      1 patch/16 hrs.
                                                                                                                                      Same as
                                                                                                                                                                 Treatment Duration: 8 wks.

              contact me upon receiving this referral from NSMC.                                          * Nicoderm CQ     Initial:  1 patch/24 hrs.            Treatment Duration: 8 wks.
                                                                                                            21 mg           MAX:      Same as above
              _______________________________________________________________________                                                         14 mg
                                                                                                                                              7 mg
              SIGNATURE OF THE PATIENT OR PATIENT’S REPRESENTATIVE                                                                                       DATE
              _______________________________________________________________________                                                                ______________________ 1–2 hrs.
                                                                                                                                              Nicorette®    Initial: 1 piece every                                                       Treatment Duration: 8–12 wks.
              PRINTED NAME OF PATIENT REPRESENTATIVE                                                                                                                  PATIENT
                                                                                                                                              2 mg RELATIONSHIP TO24 pieces/24 hrs.
                                                                                                                                              4 mg
              ____ ____ ____ ____ ____ ____               5/03                                                                              LOZENGE behind Smoking Questionnaire
                                                                                                                                             File in chart
                                                                                                                                              Commit®                                      1 lozenge/1–2 hrs. (wks 1–6)                  Treatment Duration: 12 wks.
                                                                                                                                              2 mg                                         1 lozenge/2–4 hrs. (wks 7–9)
                                                                                                                                              4 mg                                         1 lozenge/4–8 hrs. (wks 10–12)
                                                                                                                                            NASAL SPRAY
                                                                                                                                              Nicotrol® NS                Initial:         1–2 doses/hr.                                 Treatment Duration: 3–6 mos.
                                                                                                                                              10 mg/ml                    MAX:             5 doses/hr. or 40 doses/day
                                                                                                                                              Nicotrol® Inhaler           Initial:         6–16 cartridges/day                           Treatment Duration: 3–6 mos.
                                                                                                                                              10 mg/cartridge             MAX:             16 cartridges/day

                                                                                                                                            NON-NICOTINE MEDICATION
                                                                                                                                            BUPROPION HCL SR
                                                                                                                                            * Zyban                       Initial:         150 mg/day (days 1–3)                         Treatment Duration: 7–12 wks.
                                                                                                                                            150 mg tablets                                 300 mg/day (day 4+)
                                                                                                                                                                          MAX:             300 mg/day
                                                                                                                                            Inclusion of this adult dosage chart is strictly for the convenience of the prescribing provider. Please consult the Physicians’ Desk
                                                                                                                                            Reference for complete product information and contraindications. This chart does not indicate or authorize insurance benefit coverage for
                                                                                                                                            any of these medications. For insurance benefit information, the patient will need to contact his/her insurer directl. The cost or provision
                                                                                                                                            of these medications is not included as any part of the Try-To-STOP TOBACCO Resource Center of Massachusetts or QuitWorks program.

                                                                                                                                            * NORMALLY AVAILABLE FROM HOSPITAL PHARMACY
                                                                                                                                                                                          Make smoking history.

                                                                                        Quitline Operations: A Practical Guide to Promising Approaches                                                                                                                                           B9
Appendix B

             QuitWorks Counseling                                                    The Evidence Base
             Overview                                                                for QuitWorks
             The Try-To-STOP TOBACCO Resource Center*,                               Clinical trials clearly demonstrate that brief smoking
             funded by the Massachusetts Department of Public                        cessation counseling by physicians, dentists, and
             Health, provides QuitWorks counseling services                          other clinicians significantly increases smoking
             to all state residents. For patients who have quit                      cessation rates in adult patients. Utilizing evidence
             or who are ready to take action by choosing a quit                      determined from these trials, the U.S. Public Health
             date in the near future, QuitWorks offers proactive                     Service published in 2000 a clinical practice guideline
             telephone counseling or referral to local tobacco                       for treating nicotine dependence. Known as the
             treatment services. QuitWorks uses the American                         5 A’s Intervention, these guidelines recommend
             Cancer Society’s Quitline to provide the multi-                         that the clinician:
             session, telephone counseling, as outlined below                           I ASK about tobacco use at each visit
             by the American Cancer Society.
                                                                                        I ADVISE all tobacco users to stop
              SESSION        SCHEDULE                     OBJECTIVES                    I ASSESS desire and willingness to quit
                         Immediately          Establish rapport • Determine             I ASSIST patients in quitting
                 1       following intake
                         call to 1–7 days
                                              reasons for smoking, reasons
                                              for quitting, and concerns about          I ARRANGE follow-up to support and
                         after, scheduled     quitting • Discuss nicotine
                         per caller           addiction • Answer questions,               reinforce patient efforts
                         convenience          concerns regarding quit date
                                                                                     The evidence supporting the guideline showed
                         OPTIMAL              Aid caller in preparation for quit
                                                                                     that brief physician advice to quit improved patient
                 2       2 days before
                         quit date
                                              day • Assess status of stop-smoking
                                              medications and discuss further        cessation rates and the addition of brief counseling
                                              if needed • Discuss and practice
                                              thought and action strategies          (under three minutes) increased the cessation
                         1–3 days before
                         quit date                                                   rates even more. Behavioral counseling (including
                         OPTIMAL              Assess quit status and emotional       telephone-based services) and pharmacotherapy
                 3       1 day after
                         quit date
                                              state • Conduct appropriate
                                              session based upon caller’s quit
                                                                                     (nicotine gum, patch, nasal spray, lozenge and
                                              status • Assess caller’s use of        inhaler) or the antidepressant bupropion (Zyban®
                         1–2 days after       quit strategies and stop-smoking       or Wellbutrin SR®) were found to be effective.
                         quit date            medications • Plan for handling
                                              future tough situations that will      A combination of counseling and pharmacotherapy
                                              come up in the next week
                                                                                     produced the best results.
                         OPTIMAL              Assess quit status, emotional state,
                 4       7 days after
                         Session 3
                                              and use of stop-smoking medications
                                              • Assess caller’s motivation to
                                                                                     Physician or clinician advice based on health issues
                                              remain a non-smoker • Plan for         provides a strong incentive for smokers to quit and
                         5–9 days after       handling future tough situations       to continue their efforts to avoid tobacco. QuitWorks
                         Session 3            that will come up in the next week
                                              • Reinforce caller for their success   reinforces and enhances clinician efforts and supports
                         OPTIMAL              Assess quit status, emotional          successful quit attempts.
                 5       14 days after
                         Session 3
                                              state, and use of stop-smoking
                                              medications • Assess caller’s          Proactive Telephone Counseling Works: The
                                              motivation to remain a non-smoker
                                              •Remind caller to prepare to
                                                                                     Public Health Service Clinical Practice Guideline
                         12–16 days
                         after Session 3      cope with urges to smoke in            recommends proactive telephone counseling,
                                              advance; plan for action and
                                              thought strategies, and do mental      as treatments involving person-to-person contact
                                              rehearsals of them • Reinforce         (individual, group, or proactive telephone
                                              caller for their success
                                                                                     counseling) are consistently effective.
             * See page 9 for a list of all services.

B10   Quitline Operations: A Practical Guide to Promising Approaches
                                                                                                         Appendix B

     Try-To-STOP TOBACCO Resource Center of Massachusetts

FUNDED BY the Massachusetts Department of Public Health, the Try-To-STOP TOBACCO
Resource Center of Massachusetts is the service provider for QuitWorks. Its four interrelated
services—the toll-free tobacco helpline, the two websites, www.trytostop.org and www.quitworks.org,
and the Massachusetts Tobacco Education Clearinghouse—offer cessation support to Massachusetts
smokers and information and tobacco education resources to the public, tobacco control professionals,
health care providers, and educators.

1-800-TRY-TO-STOP Toll-Free Tobacco Helpline
   I Information on tobacco, referrals to local tobacco treatment programs,
     and free telephone tobacco counseling
   I Quit Tips available 24 hours a day
   I Services in English and Spanish (1-800-8-DÉJALO) with translators in additional
     languages; recorded Quit Tips in English and Spanish (1-800-9-GET-A-TIP)
   I TTY line–1-800-TDD-1477 (1-800-833-1477)

Massachusetts Tobacco Education Clearinghouse (MTEC)
   I Tobacco educational materials offered at low cost to tobacco control programs
     and health care providers in Massachusetts
   I Resource library of more than 3,000 books, reports, curricula, and videos open
     to the public for research purposes

   I Website providing tobacco information, quitting assistance, and links
   I The Quit Wizard—a state-of-the-art, self-paced, user-friendly, interactive program
     for tobacco users who want to quit smoking
   I On-line community, bulletin boards, success stories, and ask-the-expert features

   I Website for the QuitWorks program, providing information on the program and
     the QuitWorks collaboration
   I QuitWorks enrollment forms, patient materials, provider and office practice guides,
     and re-order instructions available on-line

                                                                     RESOURCE CENTER OF MASSACHUSETTS

                                                Quitline Operations: A Practical Guide to Promising Approaches   B11
Appendix B

                     To Get Started with QuitWorks, Contact:
                     • Donna Warner, QuitWorks Project Director, Massachusetts Department of Public Health
                       at donna.warner@state.ma.us or

                     • Beth Ewy, University of Massachusetts Medical School at beth.ewy@umassmed.edu

                        QuitWorks is a collaboration of the Massachusetts Department of Public Health with major Massachusetts
                        health plans. The QuitWorks Guide for Hospitals and Health Centers was developed by the QuitWorks
                        Institutional Task Group.

                              Institutional Task Group Members:

                                   I   Massachusetts Department of Public Health
                                   I   University of Massachusetts Medical School
                                   I   Massachusetts General Hospital, Tobacco Research and Treatment Center
                                   I   Try-To-STOP TOBACCO Resource Center (JSI Research and Training Institute, Inc.)
                                   I   Boston Medical Center’s HealthNet Plan

B12   Quitline Operations: A Practical Guide to Promising Approaches
                                                        Appendix C

Quitline Operations: A Practical Guide to Promising Approaches   C1
Appendix D

             The                Program is YOUR direct link to the Wisconsin Tobacco Quit Line. The Quit Line
             provides free, tobacco treatment counseling. With the                 Program, you no longer have to
             take the first step in calling the Quit Line - a Quit Line counselor will call you.

             It’s a simple three-step process:
                  1. You complete and sign the consent from that your healthcare provider gives you.
                  2. Your healthcare provider faxes the form to the Wisconsin Tobacco Quit Line.
                  3. Once the Quit Line receives the consent form, a trained counselor will call you within 72
                      hours to talk you through the quitting process and help you develop a personalized quit plan.

             Studies have shown that medication plus counseling makes your chance of quitting tobacco
             successfully three to four times better. The Quit Line counselors will work with you on your
             specific smoking patterns, and can help you find ways to cope with quitting tobacco. In addition
             to counseling, the Quit Line provides free materials on quitting, as well as information on local

             That’s up to you. The Quit Line will make up to three attempts to reach you. After your first call,
             you will determine how many times you wish to be called – one, two, or four times.

             Yes! Only if you agree, will the Quit Line provide information to your doctors. The consent does
             not allow health care workers to release this information to anyone else.

             No. The Wisconsin Tobacco Quit Line and the                  Program are free to all Wisconsin

D1   Quitline Operations: A Practical Guide to Promising Approaches
                                                        Appendix E

Quitline Operations: A Practical Guide to Promising Approaches   E1

     Quitline Operations: A Practical Guide to Promising Approaches

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